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de Moura Pedro RA, Besen BAMP, Mendes PV, Gomes ACM, de Carvalho MT, Malbouisson LMS, Park M, Taniguchi LU. Adverse events leading to intensive care unit admission in a low-and-middle-income-country: A prospective cohort study and a systematic review. J Crit Care 2024; 80:154510. [PMID: 38150833 DOI: 10.1016/j.jcrc.2023.154510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Adverse events (AE) are frequent in critical care and could be even more prevalent in LMIC due to a shortage of ICU beds and Human resources. There is limited data on how relevant AE are among the reasons for ICU admission, being all of which published by High-Income-Countries services. Our main goal is to describe the rate of adverse events-related ICU admissions and their preventability in a LMIC scenario, comparing our results with previous data. METHODS This was a prospective cohort study, during a one-year period, in two general ICUs from a tertiary public academic hospital. Our exposure of interest was ICU admission related to an AE in adult patients, we further characterized their preventability and clinical outcomes. We also performed a systematic review to identify and compare previous published data on ICU admissions due to AE. RESULTS Among all ICU admissions, 12.1% were related to an AE (9.8% caused by an AE, 2.3% related but not directly caused by an AE). These ICU admissions were not associated with a higher risk of death, but most of them were potentially preventable (70.9% of preventability rate, representing 8.6% of all ICU admissions). The meta-analysis resulted in a proportion of ICU admissions due to AE of 11% (95% CI 6%-16%), with a preventability rate of 54% (95% CI 42%-66%). CONCLUSIONS In this prospective cohort, adverse events were a relevant reason for ICU admission. This result is consistent with data retrieved from non-LMIC as shown in our meta-analysis. The high preventability rate described reinforces that quality and safety programs could work as a tool to optimize scarce resources.
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Affiliation(s)
| | | | - Pedro Vitale Mendes
- Intensive Care Unit, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | | | - Marcelo Park
- Intensive Care Unit, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Intensive Care Unit, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Hospital Sírio-Libanês, São Paulo, SP, Brazil
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Vianna FSL, Neves LL, Testa R, Nassar AP, Peres JHF, da Silva RÁJ, de Paula Sales F, Raglione D, Del Bianco Madureira B, Dalfior L, Malbouisson LMS, Ribeiro U, da Silva JM. Impact of the COVID-19 Pandemic on the Outcomes of Patients Undergoing Oncological Surgeries: CORONAL Study. Ann Surg Oncol 2024:10.1245/s10434-024-15152-9. [PMID: 38530529 DOI: 10.1245/s10434-024-15152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/20/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND The impact of coronavirus disease 2019 (COVID-19) on postoperative recovery from oncology surgeries should be understood for the clinical decision-making. Therefore, this study was designed to evaluate the postoperative cumulative 28-day mortality and the morbidity of surgical oncology patients during the COVID-19 pandemic. METHODS This retrospective cohort study included patients consecutively admitted to intensive care units (ICU) of three centres for postoperative care of oncologic surgeries between March to June 2019 (first phase) and March to June 2020 (second phase). The primary outcome was cumulative 28-day postoperative mortality. Secondary outcomes were postoperative organic dysfunction and the incidence of clinical complications. Because of the possibility of imbalance between groups, adjusted analyses were performed: Cox proportional hazards model (primary outcome) and multiple logistic regression model (secondary outcomes). RESULTS After screening 328 patients, 291 were included. The proportional hazard of cumulative 28-day mortality was higher in the second phase than that in the first phase in the Cox model, with the adjusted hazard ratio of 4.35 (95% confidence interval [CI] 2.15-8.82). The adjusted incidences of respiratory complications (odds ratio [OR] 5.35; 95% CI 1.42-20.11) and pulmonary infections (OR 1.53; 95% CI 1.08-2.17) were higher in the second phase. However, the adjusted incidence of other infections was lower in the second phase (OR 0.78; 95% CI 0.67-0.91). CONCLUSIONS Surgical oncology patients who underwent postoperative care in the intensive care unit during the COVID-19 pandemic had higher hazard of 28-day mortality. Furthermore, these patients had higher odds of respiratory complications and pulmonary infections. Trials registration The study is registered in the Brazilian Registry of Clinical Trials under the code RBR-8ygjpqm, UTN code U1111-1293-5414.
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Affiliation(s)
- Felipe Souza Lima Vianna
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
- Departamento de Pacientes Graves, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Renato Testa
- Fundação Antonio Prudente- A C Camargo Cancer Center, São Paulo, SP, Brazil
| | | | | | | | | | - Dante Raglione
- Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | | | - Luiz Dalfior
- Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - Ulysses Ribeiro
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - João Manoel da Silva
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Hospital do Câncer de Barretos- Fundação Pio XII, Barretos, SP, Brazil
- Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
- Departamento de Pacientes Graves, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Roepke RML, Besen BAMP, Daltro-Oliveira R, Guazzelli RM, Bassi E, Salluh JIF, Damous SHB, Utiyama EM, Malbouisson LMS. Predictive Performance for Hospital Mortality of SAPS 3, SOFA, ISS, and New ISS in Critically Ill Trauma Patients: A Validation Cohort Study. J Intensive Care Med 2024; 39:44-51. [PMID: 37448331 DOI: 10.1177/08850666231188051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
Background: It is not known whether anatomical scores perform better than general critical care scores for trauma patients admitted to the intensive care unit (ICU). We compare the predictive performance for hospital mortality of general critical care scores (SAPS 3 and SOFA) with anatomical injury-based scores (Injury Severity Score [ISS] and New ISS [NISS]). Methods: Retrospective cohort study of patients admitted to a specialized trauma ICU from a tertiary hospital in São Paulo, Brazil between May, 2012 and January, 2016. We retrieved data from the ICU database for critical care scores and calculated ISS and NISS from chart data and whole body computed tomography results. We compared the predictive performance for hospital mortality of each model through discrimination, calibration, and decision-curve analysis. Results: The sample comprised 1053 victims of trauma admitted to the ICU, with 84.2% male patients and mean age of 40 (±18) years. Main injury mechanism was blunt trauma (90.7%). Traumatic brain injury was present in 67.8% of patients; 43.3% with severe TBI. At the time of ICU admission, 846 patients (80.3%) were on mechanical ventilation and 644 (64.3%) on vasoactive drugs. Hospital mortality was 23.8% (251). Median SAPS 3 was 41; median maximum SOFA within 24 h of admission, 7; ISS, 29; and NISS, 41. AUROCs (95% CI) were: SAPS 3 = 0.786 (0.756-0.817), SOFA = 0.807 (0.778-0.837), ISS = 0.616 (0.577-0.656), and NISS = 0.689 (0.649-0.729). In pairwise comparisons, SAPS 3 and SOFA did not differ, while both outperformed the anatomical scores (p < .001). Maximum SOFA within 24 h of admission presented the best calibration and net benefit in decision-curve analysis. Conclusions: Trauma-specific anatomical scores have fair performance in critically ill trauma patients and are outperformed by SAPS 3 and SOFA. Illness severity is best characterized by organ dysfunction and physiological variables than anatomical injuries.
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Affiliation(s)
- Roberta Muriel Longo Roepke
- Trauma and Acute Care Surgery ICU, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, SP, Brazil
- Medical ICU, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Renato Daltro-Oliveira
- Medical ICU, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Estevão Bassi
- Trauma and Acute Care Surgery ICU, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Sérgio Henrique Bastos Damous
- Trauma and Acute Care Surgery ICU, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- Trauma and Acute Care Surgery ICU, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Surgical ICU, Anesthesiology Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Brasil S, de Carvalho Nogueira R, Salinet ÂSM, Yoshikawa MH, Teixeira MJ, Paiva W, Malbouisson LMS, Bor-Seng-Shu E, Panerai RB. Critical Closing Pressure and Cerebrovascular Resistance Responses to Intracranial Pressure Variations in Neurocritical Patients. Neurocrit Care 2023; 39:399-410. [PMID: 36869208 PMCID: PMC10541829 DOI: 10.1007/s12028-023-01691-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Critical closing pressure (CrCP) and resistance-area product (RAP) have been conceived as compasses to optimize cerebral perfusion pressure (CPP) and monitor cerebrovascular resistance, respectively. However, for patients with acute brain injury (ABI), the impact of intracranial pressure (ICP) variability on these variables is poorly understood. The present study evaluates the effects of a controlled ICP variation on CrCP and RAP among patients with ABI. METHODS Consecutive neurocritical patients with ICP monitoring were included along with transcranial Doppler and invasive arterial blood pressure monitoring. Internal jugular veins compression was performed for 60 s for the elevation of intracranial blood volume and ICP. Patients were separated in groups according to previous intracranial hypertension severity, with either no skull opening (Sk1), neurosurgical mass lesions evacuation, or decompressive craniectomy (DC) (patients with DC [Sk3]). RESULTS Among 98 included patients, the correlation between change (Δ) in ICP and the corresponding ΔCrCP was strong (group Sk1 r = 0.643 [p = 0.0007], group with neurosurgical mass lesions evacuation r = 0.732 [p < 0.0001], and group Sk3 r = 0.580 [p = 0.003], respectively). Patients from group Sk3 presented a significantly higher ΔRAP (p = 0.005); however, for this group, a higher response in mean arterial pressure (change in mean arterial pressure p = 0.034) was observed. Exclusively, group Sk1 disclosed reduction in ICP before internal jugular veins compression withholding. CONCLUSIONS This study elucidates that CrCP reliably changes in accordance with ICP, being useful to indicate ideal CPP in neurocritical settings. In the early days after DC, cerebrovascular resistance seems to remain elevated, despite exacerbated arterial blood pressure responses in efforts to maintain CPP stable. Patients with ABI with no need of surgical procedures appear to remain with more effective ICP compensatory mechanisms when compared with those who underwent neurosurgical interventions.
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Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil.
| | - Ricardo de Carvalho Nogueira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Ângela Salomão Macedo Salinet
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Márcia Harumy Yoshikawa
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Wellingson Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | | | - Edson Bor-Seng-Shu
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, School of Life Sciences, University of Leicester, Leicester, UK
- National Institute for Health and Care Research, Cardiovascular Research Centre, Glenfield Hospital, University of Leicester, Leicester, UK
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Balzi APDCC, Otsuki DA, Andrade L, Paiva W, Souza FL, Aureliano LGC, Malbouisson LMS. Can a Therapeutic Strategy for Hypotension Improve Cerebral Perfusion and Oxygenation in an Experimental Model of Hemorrhagic Shock and Severe Traumatic Brain Injury? Neurocrit Care 2023; 39:320-330. [PMID: 37535176 DOI: 10.1007/s12028-023-01802-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Restoration of brain tissue perfusion is a determining factor in the neurological evolution of patients with traumatic brain injury (TBI) and hemorrhagic shock (HS). In a porcine model of HS without neurological damage, it was observed that the use of fluids or vasoactive drugs was effective in restoring brain perfusion; however, only terlipressin promoted restoration of cerebral oxygenation and lower expression of edema and apoptosis markers. It is unclear whether the use of vasopressor drugs is effective and beneficial during situations of TBI. The objective of this study is to compare the effects of resuscitation with saline solution and terlipressin on cerebral perfusion and oxygenation in a model of TBI and HS. METHODS Thirty-two pigs weighing 20-30 kg were randomly allocated into four groups: control (no treatment), saline (60 ml/kg of 0.9% NaCl), terlipressin (2 mg of terlipressin), and saline plus terlipressin (20 ml/kg of 0.9% NaCl + 2 mg of terlipressin). Brain injury was induced by lateral fluid percussion, and HS was induced through pressure-controlled bleeding, aiming at a mean arterial pressure (MAP) of 40 mmHg. After 30 min of circulatory shock, resuscitation strategies were initiated according to the group. The systemic and cerebral hemodynamic and oxygenation parameters, lactate levels, and hemoglobin levels were evaluated. The data were subjected to analysis of variance for repeated measures. The significance level established for statistical analysis was p < 0.05. RESULTS The terlipressin and saline plus terlipressin groups showed an increase in MAP that lasted until the end of the experiment (p < 0.05). There was a notable increase in intracranial pressure in all groups after starting treatment for shock. Cerebral perfusion pressure and cerebral oximetry showed no improvement after hemodynamic recovery in any group. The groups that received saline at resuscitation had the lowest hemoglobin concentrations after treatment. CONCLUSIONS The treatment of hypotension in HS with saline and/or terlipressin cannot restore cerebral perfusion or oxygenation in experimental models of HS and severe TBI. Elevated MAP raises intracranial pressure owing to brain autoregulation dysfunction caused by TBI.
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Affiliation(s)
- Ana Paula de Carvalho Canela Balzi
- Anesthesiology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
- Divisão de Anestesia do ICHC, UTI Cirúrgica Pediátrica, Av. Enéas Carvalho de Aguiar, 255 - 8° Andar, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
| | - Denise Aya Otsuki
- Medical Research Laboratory -LIM-08, Anesthesiology Department, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lucia Andrade
- Nephrology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellingson Paiva
- Neurosurgery Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Felipe Lima Souza
- Medical Research Laboratory, Nephrology Department, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Guilherme Cernaglia Aureliano
- Pathology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Anesthesiology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César, São Paulo, SP, 05403-000, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Gomes BC, Lobo SMA, Sá Malbouisson LM, de Freitas Chaves RC, Domingos Corrêa T, Prata Amendola C, Silva Júnior JM. Trends in perioperative practices of high-risk surgical patients over a 10-year interval. PLoS One 2023; 18:e0286385. [PMID: 37725600 PMCID: PMC10508595 DOI: 10.1371/journal.pone.0286385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/16/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION In Brazil, data show an important decrease in morbi-mortality of high-risk surgical patients over a 10-year high. The objective of this post-hoc study was to evaluate the mechanism explaining this trend in high-risk surgical patients admitted to Brazilian ICUs in two large Brazilian multicenter cohort studies performed 10 years apart. METHODS The patients included in the 2 cohorts studies published in 2008 and 2018 were compared after a (1:1) propensity score matching. Patients included were adults who underwent surgeries and admitted to the ICU afterwards. RESULTS After matching, 704 patients were analyzed. Compared to the 2018 cohort, 2008 cohort had more postoperative infections (OR 13.4; 95%CI 6.1-29.3) and cardiovascular complications (OR 1.5; 95%CI 1.0-2.2), as well as a lower survival ICU stay (HR = 2.39, 95% CI: 1.36-4.20) and hospital stay (HR = 1.64, 95% CI: 1.03-2.62). In addition, by verifying factors strongly associated with hospital mortality, it was found that the risk of death correlated with higher intraoperative fluid balance (OR = 1.03, 95% CI 1.01-1.06), higher creatinine (OR = 1.31, 95% CI 1.1-1.56), and intraoperative blood transfusion (OR = 2.32, 95% CI 1.35-4.0). By increasing the mean arterial pressure, according to the limits of sample values from 43 mmHg to 118 mmHg, the risk of death decreased (OR = 0.97, 95% CI 0.95-0.98). The 2008 cohort had higher fluid balance, postoperative creatinine, and volume of intraoperative blood transfused and lower mean blood pressure at ICU admission and temperature at the end of surgery. CONCLUSION In this sample of ICUs in Brazil, high-risk surgical patients still have a high rate of complications, but with improvement over a period of 10 years. There were changes in the management of these patients over time.
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Affiliation(s)
- Brenno Cardoso Gomes
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo-SP, Brasil
- Departamento de Medicina Integrada do Setor de Ciências da Saúde da Universidade Federal do Paraná, Curitiba-PR, Brasil
| | | | | | | | | | | | - João Manoel Silva Júnior
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo-SP, Brasil
- Hospital Israelita Albert Einstein, São Paulo-SP, Brasil
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Bassi E, Merighi CT, Tomizuka CI, Guimarães T, Novo FDCF, Damous SHB, Utiyama EM, Malbouisson LMS. Association of antimicrobial use and incidence of hospital-acquired pneumonia in critically ill trauma patients with pulmonary contusion: an observational study. Braz J Anesthesiol 2023:S0104-0014(23)00078-7. [PMID: 37541487 DOI: 10.1016/j.bjane.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Pneumonia occurs in about 20% of trauma patients with pulmonary contusions. This study aims to evaluate the association between empirical antibiotic therapy and nosocomial pneumonia in this population. METHODS Retrospective cohort of adult patients admitted to a trauma-surgical ICU. The Antibiotic Therapy Group (ATG) was defined by intravenous antibiotic use for more than 48 h starting on hospital admission, while the Conservative Group (CG) was determined by antibiotic use no longer than 48 h. Primary outcome was microbiologically documented nosocomial pneumonia within 14 days after hospital admission. Logistic regression was used to estimate the association between group allocation and primary outcome. Exploratory analyses evaluating the association between resistant strains in pneumonia and antibiotic use were performed. RESULTS The study included 177 patients with chest trauma and pulmonary contusion on CT scan. ATG were more severely ill than CG, as shown by higher Injury Severity Score, SAPS3, SOFA score, higher rates, and longer duration of mechanical ventilation. In the multivariate analysis, ATG was associated with a lower incidence of primary outcome (OR = 0.25, 95% CI 0.09-0.64; p < 0.01). Similar results were found in the sensitivity analysis with another set of variables. However, each day of antibiotic use was associated with an increased risk of pneumonia by resistant bacteria (OR = 1.18 per day, 95% CI 1.05-1.36; p < 0.01). CONCLUSIONS Empiric antibiotic therapy was independently associated with lower incidence of nosocomial pneumonia in critically ill patients with pulmonary contusion. However, each day of antibiotic use was associated with increased resistant strains in infected patients.
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Affiliation(s)
- Estevão Bassi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil; Hospital Alemão Oswaldo Cruz, Unidade de Tratamento Intensivo, São Paulo, SP, Brazil.
| | - Camila Trevizani Merighi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Carlos Issamu Tomizuka
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Thais Guimarães
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Comissão de Controle de Infecção Hospitalar, São Paulo, SP, Brazil
| | - Fernando da Costa Ferreira Novo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Sergio Henrique Bastos Damous
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Divisão de Anestesiologia, São Paulo, SP, Brazil
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Bassi E, Tomazini BM, Carneiro BV, Siqueira ARDO, Siqueira SRDO, Guimarães T, Novo FDCF, Utiyama EM, Pelosi P, Malbouisson LMS. Impact of withholding early antibiotic therapy in nonseptic surgical patients with suspected nosocomial infection: a retrospective cohort analysis. Braz J Anesthesiol 2023:S0104-0014(23)00026-X. [PMID: 36965628 DOI: 10.1016/j.bjane.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Systemic inflammatory responses mimicking infectious complications are often present in surgical patients. METHODS The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion. RESULTS Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with a posteriori confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05-1.37). CONCLUSIONS Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.
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Affiliation(s)
- Estevão Bassi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil; Hospital Alemão Oswaldo Cruz, Unidade de Tratamento Intensivo, São Paulo, SP, Brazil.
| | - Bruno Martins Tomazini
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil; Hospital Sírio-Libanês, Instituto de Ensino e Pesquisa, São Paulo, SP, Brazil
| | - Bárbara Vieira Carneiro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | | | | | - Thais Guimarães
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Controle de Infecção, São Paulo, SP, Brazil
| | - Fernando da Costa Ferreira Novo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Paolo Pelosi
- University of Genoa, Department of Surgical Sciences and Integrated Diagnostics, Genoa, Italy; San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Anaesthesia and Intensive Care, Genoa, Italy
| | - Luiz Marcelo Sá Malbouisson
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Divisão de Anestesiologia, São Paulo, SP, Brazil
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9
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Brasil S, Frigieri G, Taccone FS, Robba C, Solla DJF, de Carvalho Nogueira R, Yoshikawa MH, Teixeira MJ, Malbouisson LMS, Paiva WS. Noninvasive intracranial pressure waveforms for estimation of intracranial hypertension and outcome prediction in acute brain-injured patients. J Clin Monit Comput 2022; 37:753-760. [PMID: 36399214 PMCID: PMC9673225 DOI: 10.1007/s10877-022-00941-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/27/2022] [Indexed: 11/19/2022]
Abstract
Analysis of intracranial pressure waveforms (ICPW) provides information on intracranial compliance. We aimed to assess the correlation between noninvasive ICPW (NICPW) and invasively measured intracranial pressure (ICP) and to assess the NICPW prognostic value in this population. In this cohort, acute brain-injured (ABI) patients were included within 5 days from admission in six Intensive Care Units. Mean ICP (mICP) values and the P2/P1 ratio derived from NICPW were analyzed and correlated with outcome, which was defined as: (a) early death (ED); survivors on spontaneous breathing (SB) or survivors on mechanical ventilation (MV) at 7 days from inclusion. Intracranial hypertension (IHT) was defined by ICP > 20 mmHg. A total of 72 patients were included (mean age 39, 68% TBI). mICP and P2/P1 values were significantly correlated (r = 0.49, p < 0.001). P2/P1 ratio was significantly higher in patients with IHT and had an area under the receiving operator curve (AUROC) to predict IHT of 0.88 (95% CI 0.78–0.98). mICP and P2/P1 ratio was also significantly higher for ED group (n = 10) than the other groups. The AUROC of P2/P1 to predict ED was 0.71 [95% CI 0.53–0.87], and the threshold P2/P1 > 1.2 showed a sensitivity of 60% [95% CI 31–83%] and a specificity of 69% [95% CI 57–79%]. Similar results were observed when decompressive craniectomy patients were excluded. In this study, P2/P1 derived from noninvasive ICPW assessment was well correlated with IHT. This information seems to be as associated with ABI patients outcomes as ICP. Trial registration: NCT03144219, Registered 01 May 2017 Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03144219.
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Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Gustavo Frigieri
- Medical Investigation Laboratory 62, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hôpital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Chiara Robba
- Department of Intensive Care, Universitá degli Studi di Genoa, Genoa, Italy
| | - Davi Jorge Fontoura Solla
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Ricardo de Carvalho Nogueira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Marcia Harumy Yoshikawa
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | | | - Wellingson Silva Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
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10
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de Morais DG, Sanches TRC, Santinho MAR, Yada EY, Segura GC, Lowe D, Navarro G, Seabra VF, Taniguchi LU, Malbouisson LMS, de André CDS, Andrade L, Rodrigues CE. Urinary sodium excretion is low prior to acute kidney injury in patients in the intensive care unit. Front Nephrol 2022; 2:929743. [PMID: 37675036 PMCID: PMC10479577 DOI: 10.3389/fneph.2022.929743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/31/2022] [Indexed: 09/08/2023]
Abstract
Background The incidence of acute kidney injury (AKI) is high in intensive care units (ICUs), and a better understanding of AKI is needed. Early chronic kidney disease is associated with urinary concentration inability and AKI recovery with increased urinary solutes in humans. Whether the inability of the kidneys to concentrate urine and excrete solutes at appropriate levels could occur prior to the diagnosis of AKI is still uncertain, and the associated mechanisms have not been studied. Methods In this single-center prospective observational study, high AKI risk in ICU patients was followed up for 7 days or until ICU discharge. They were grouped as "AKI" or "No AKI" according to their AKI status throughout admission. We collected daily urine samples to measure solute concentrations and osmolality. Data were analyzed 1 day before AKI, or from the first to the fifth day of admission in the "No AKI" group. We used logistic regression models to evaluate the influence of the variables on future AKI diagnosis. The expression of kidney transporters in urine was evaluated by Western blotting. Results We identified 29 patients as "No AKI" and 23 patients as "AKI," the latter being mostly low severity AKI. Urinary sodium excretion was lower in "AKI" patients prior to AKI diagnosis, particularly in septic patients. The expression of Na+/H+ exchanger (NHE3), a urinary sodium transporter, was higher in "AKI" patients. Conclusions Urinary sodium excretion is low before an AKI episode in ICU patients, and high expressions of proximal tubule sodium transporters might contribute to this.
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Affiliation(s)
- David Gomes de Morais
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Talita Rojas Cunha Sanches
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Mirela Aparecida Rodrigues Santinho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Yuki Yada
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Gabriela Cardoso Segura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Diogo Lowe
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Guilherme Navarro
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Victor Faria Seabra
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carmen Diva Saldiva de André
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Lúcia Andrade
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camila Eleuterio Rodrigues
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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11
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Correia PC, Gomes de Macedo P, Santos JFG, Moreira Júnior JR, de Oliveira C, Malbouisson LMS. Impact of customised ICU handover protocol on the quality of ICU discharge reports. BMJ Open Qual 2022; 11:bmjoq-2021-001647. [PMID: 35977742 PMCID: PMC9389091 DOI: 10.1136/bmjoq-2021-001647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this investigation was to evaluate the impact of implementing a handover protocol, based on a standardised mnemonic tool specific for a cardiovascular intensive care unit (ICU), on the quality of information transferred during ICU discharge. Methods In this prospective pre–post study, we evaluated the implementation of an ICU discharge handover protocol in 168 patients who underwent coronary artery bypass graft surgery. The primary outcome was the quality of the information. In the preintervention phase, 84 ICU standard discharge reports were evaluated. During the intervention period, a new handover protocol which included a written discharge report based on the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) mnemonic tool was implemented. After the intervention, 84 new reports were assessed. The reports were evaluated by the ward physicians and by an external independent examiner using a standardised questionnaire. ICU discharge time and postoperative length of stay were also analysed. Results The overall quality of the reports was evaluated as ‘completely understood’ by the ward physicians in 17 patients (21%) in the preintervention phase compared with 45 patients (54.9%) in the postintervention phase (p<0.001). The independent examiner classified one report (1.2% of the total number) as ‘excellent’ in the preintervention phase and 30 (35.7%) in the postintervention phase (p<0.001). After protocol implementation, patients were released from the ICU 58 min later (p<0.001). There was no difference in the length of postoperative hospital stay. Conclusion Implementation of a customised handover protocol when discharging patients from the ICU was associated with improvement in the quality of the information transferred but also with ICU discharge occurring at a later time of day.
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Affiliation(s)
- Paulo César Correia
- Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
- Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
| | | | | | | | | | - Luiz Marcelo Sá Malbouisson
- Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
- Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
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12
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Vinicius Santinelli Pestana D, Raglione D, Junior LD, Liberatti CDSP, Braga EC, Ezequiel VADL, Alves ADS, Mauro JG, Dias JODA, Moreira PTF, Madureira BDB, Paiva LP, de Lucena BMN, Junior JMS, Malbouisson LMS. Stress and substance abuse among workers during the COVID-19 pandemic in an intensive care unit: A cross-sectional study. PLoS One 2022; 17:e0263892. [PMID: 35143590 PMCID: PMC8830709 DOI: 10.1371/journal.pone.0263892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/28/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Professionals working in intensive care units (ICUs) during the COVID-19 pandemic have been exposed to stressful situations and increased workload. The association between symptoms of traumatic stress disorders, substance abuse and personal/occupational characteristics of Brazilian COVID-19-ICU workers is still to be addressed. Our aim was to evaluate the prevalence of those conditions and to find if those associations exist. Methods In this observational, single-center, cross-sectional study, all professionals working in a COVID-19 ICU were invited to fill an anonymous form containing screening tools for traumatic stress disorders and substance abuse, and a section with questions regarding personal and occupational information. Results Three hundred seventy-six ICU professionals participated. Direct exposure to patients infected by COVID-19, history of relatives infected by COVID-19, and sex (female) were significantly associated with signs and symptoms of traumatic stress disorders. 76.5% of the participants had scores compatible with a diagnosis of traumatic stress disorders. Moreover, the prevalence of scores suggestive of Tobacco and Alcohol abuse were 11.7% and 24.7%, respectively. Conclusion ICU workers had significantly elevated scores on both screening forms. Providing psycho-social support to ICU professionals may prevent future problems with traumatic stress disorders or substance abuse.
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Affiliation(s)
- Diego Vinicius Santinelli Pestana
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- * E-mail:
| | - Dante Raglione
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Dalfior Junior
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Caroline de Souza Pereira Liberatti
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Elisangela Camargo Braga
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vitor Augusto de Lima Ezequiel
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Adriana da Silva Alves
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Juliana Gil Mauro
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Omar de Araújo Dias
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Thadeu Fantinato Moreira
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Bruno Del Bianco Madureira
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lilian Petroni Paiva
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Bruno Melo Nóbrega de Lucena
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - João Manoel Silva Junior
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Department of Anesthesiology, Intensive Care Unit, Instituto do Câncer do Estado de São Paulo/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Brasil S, Solla DJF, Nogueira RDC, Teixeira MJ, Malbouisson LMS, Paiva WDS. A Novel Noninvasive Technique for Intracranial Pressure Waveform Monitoring in Critical Care. J Pers Med 2021; 11:1302. [PMID: 34945774 PMCID: PMC8707681 DOI: 10.3390/jpm11121302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We validated a new noninvasive tool (B4C) to assess intracranial pressure waveform (ICPW) morphology in a set of neurocritical patients, correlating the data with ICPW obtained from invasive catheter monitoring. MATERIALS AND METHODS Patients undergoing invasive intracranial pressure (ICP) monitoring were consecutively evaluated using the B4C sensor. Ultrasound-guided manual internal jugular vein (IJV) compression was performed to elevate ICP from the baseline. ICP values, amplitudes, and time intervals (P2/P1 ratio and time-to-peak [TTP]) between the ICP and B4C waveform peaks were analyzed. RESULTS Among 41 patients, the main causes for ICP monitoring included traumatic brain injury, subarachnoid hemorrhage, and stroke. Bland-Altman's plot indicated agreement between the ICPW parameters obtained using both techniques. The strongest Pearson's correlation for P2/P1 and TTP was observed among patients with no cranial damage (r = 0.72 and 0.85, respectively) to the detriment of those who have undergone craniotomies or craniectomies. P2/P1 values of 1 were equivalent between the two techniques (area under the receiver operator curve [AUROC], 0.9) whereas B4C cut-off 1.2 was predictive of intracranial hypertension (AUROC 0.9, p < 000.1 for ICP > 20 mmHg). CONCLUSION B4C provided biometric amplitude ratios correlated with ICPW variation morphology and is useful for noninvasive critical care monitoring.
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Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | | | - Wellingson da Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
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14
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Brasil S, Renck AC, Taccone FS, Fontoura Solla DJ, Tomazini BM, Wayhs SY, Fonseca S, Bassi E, Lucena B, De Carvalho Nogueira R, Paiva W, Teixeira MJ, Frade Costa EM, Sá Malbouisson LM. Obesity and its implications on cerebral circulation and intracranial compliance in severe COVID-19. Obes Sci Pract 2021; 7:751-759. [PMID: 34226849 PMCID: PMC8242615 DOI: 10.1002/osp4.534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Multiple factors have been identified as causes of intracranial compliance impairment (ICCI) among patients with obesity. On the other hand, obesity has been linked with worst outcomes in COVID-19. Thus, the hypothesis of severe acute respiratory syndrome (SARS) conducing to cerebral hemodynamic disorders (CHD) able to worsen ICCI and play an additional role on prognosis determination for COVID-19 among obese patients becomes suitable. Methods 50 cases of SARS by COVID-19 were evaluated, for the presence of ICCI and cerebrovascular circulatory disturbances in correspondence with whether unfavorable outcomes (death or impossibility for mechanical ventilation weaning [MVW]) within 7 days after evaluation. The objective was to observe whether obese patients (BMI ≥ 30) disclosed worse outcomes and tests results compared with lean subjects with same clinical background. Results 23 (46%) patients among 50 had obesity. ICCI was verified in 18 (78%) obese, whereas in 13 (48%) of 27 non-obese (p = 0,029). CHD were not significantly different between groups, despite being high prevalent in both. 69% unfavorable outcomes were observed among obese and 44% for lean subjects (p = 0,075). Conclusion In the present study, intracranial compliance impairment was significantly more observed among obese subjects and may have contributed for SARS COVID-19 worsen prognosis.
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Katayama HT, Gomes BC, Lobo SMA, Chaves RCDF, Corrêa TD, Assunção MSC, Serpa Neto A, Malbouisson LMS, Silva-Jr JM. The effects of acute kidney injury in a multicenter cohort of high-risk surgical patients. Ren Fail 2021; 43:1338-1348. [PMID: 34579622 PMCID: PMC8477947 DOI: 10.1080/0886022x.2021.1977318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Patients who develop post-operative acute kidney injury (AKI) have a poor prognosis, especially when undergoing high-risk surgery. Therefore, the objective of this study was to evaluate the outcome of patients with AKI acquired after non-cardiac surgery and the possible risk factors for this complication. METHODS A multicenter, prospective cohort study with patients admitted to intensive care units (ICUs) after non-cardiac surgery was conducted to assess whether they developed AKI. The patients who developed AKI were then compared to non-AKI patients. RESULTS A total of 29 ICUs participated, of which 904 high-risk surgical patients were involved in the study. The occurrence of AKI in the post-operative period was 15.8%, and the mortality rate of post-operative AKI patients at 28 days was 27.6%. AKI was strongly associated with 28-day mortality (OR = 2.91; 95% CI 1.51-5.62; p = 0.001), and a higher length of ICU and hospital stay (p < 0.001). Independent factors for the risk of developing AKI were pre-operative anemia (OR = 7.01; 95% CI 1.69-29.07), elective surgery (OR = 0.45; 95% CI 0.21-0.97), SAPS 3 (OR = 1.04; 95% CI 1.02-1.06), post-operative vasopressor use (OR = 2.47; 95% CI 1.34-4.55), post-operative infection (OR = 8.82; 95% CI 2.43-32.05) and the need for reoperation (OR= 7.15; 95% CI 2.58-19.79). CONCLUSION AKI was associated with the risk of death in surgical patients and those with anemia before surgery, who had a higher SAPS 3, needed a post-operative vasopressor, or had a post-operative infection or needed reoperation were more likely to develop AKI post-operatively.
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Affiliation(s)
| | | | | | | | | | | | | | | | - João Manoel Silva-Jr
- Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
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Brasil S, Solla DJF, Nogueira RDC, Jacobsen Teixeira M, Malbouisson LMS, Paiva WS. Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform. Brain Sci 2021; 11:brainsci11080971. [PMID: 34439590 PMCID: PMC8392489 DOI: 10.3390/brainsci11080971] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/06/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Morphological alterations in intracranial pressure (ICP) pulse waveform (ICPW) secondary to intracranial hypertension (ICP >20 mmHg) and a reduction in intracranial compliance (ICC) are well known indicators of neurological severity. The exclusive exploration of modifications in ICPW after either the loss of skull integrity or surgical procedures for intracranial hypertension resolution is not a common approach studied. The present study aimed to assess the morphological alterations in ICPW among neurocritical care patients with skull defects and decompressive craniectomy (DC) by comparing the variations in ICPW features according to elevations in mean ICP values. METHODS Patients requiring ICP monitoring because of acute brain injury were included. A continuous record of 10 min-length for the beat-by-beat analysis of ICPW was performed, with ICP elevation produced by means of ultrasound-guided manual internal jugular vein compression at the end of the record. ICPW features (peak amplitude ratio (P2/P1), time interval to pulse peak (TTP) and pulse amplitude) were counterweighed between baseline and compression periods. Results were distributed for three groups: intact skull (exclusive burr hole for ICP monitoring), craniotomy/large fractures (group 2) or DC (group 3). RESULTS 57 patients were analyzed. A total of 21 (36%) presented no skull defects, 21 (36%) belonged to group 2, whereas 15 (26%) had DC. ICP was not significantly different between groups: ±15.11 for intact, 15.33 for group 2 and ±20.81 mmHg for group 3, with ICP-induced elevation also similar between groups (p = 0.56). Significant elevation was observed for the P2/P1 ratio for groups 1 and 2, whereas a reduction was observed in group 3 (elevation of ±0.09 for groups 1 and 2, but a reduction of 0.03 for group 3, p = 0.01), and no significant results were obtained for TTP and pulse amplitudes. CONCLUSION In the present study, intracranial pressure pulse waveform analysis indicated that intracranial compliance was significantly more impaired among decompressive craniectomy patients, although ICPW indicated DC to be protective for further influences of ICP elevations over the brain. The analysis of ICPW seems to be an alternative to real-time ICC assessment.
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Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
- Correspondence:
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | | | - Wellingson Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
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Silva JM, Katayama HT, Lopes FMV, Toledo DO, Amendola CP, Oliveira FDS, Andraus LMR, Carmona MJC, Lobo SM, Malbouisson LMS. Referral to immediate postoperative care in an intensive care unit from the perspective of anesthesiologists, surgeons, and intensive care physicians: a cross-sectional questionnaire. Braz J Anesthesiol 2021; 71:265-270. [PMID: 33930339 PMCID: PMC9373420 DOI: 10.1016/j.bjane.2021.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 03/01/2021] [Accepted: 03/13/2021] [Indexed: 12/16/2022] Open
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.
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Affiliation(s)
- João Manoel Silva
- Hospital Servidor Público Estadual de São Paulo, Departamento de Anestesiologia, São Paulo, SP, Brazil; Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clínicas, Divisão de Anestesiologia, São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, Departamento de Pacientes Graves, São Paulo, SP, Brazil; Hospital de Câncer de Barretos, Departamento de Anestesiologia e Terapia Intesiva, Barretos, SP, Brazil.
| | - Henrique Tadashi Katayama
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clínicas, Divisão de Anestesiologia, São Paulo, SP, Brazil
| | | | - Diogo Oliveira Toledo
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clínicas, Divisão de Anestesiologia, São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, Departamento de Pacientes Graves, São Paulo, SP, Brazil
| | - Cristina Prata Amendola
- Hospital de Câncer de Barretos, Departamento de Anestesiologia e Terapia Intesiva, Barretos, SP, Brazil
| | | | | | - Maria José C Carmona
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clínicas, Divisão de Anestesiologia, São Paulo, SP, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto (FAMERP), Hospital de Base de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clínicas, Divisão de Anestesiologia, São Paulo, SP, Brazil
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Carmona MJC, Quintão VC, de Melo BF, André RG, Kayano RP, Perondi B, Miethke-Morais A, Rocha MC, Malbouisson LMS, Auler-Júnior JOC. Transforming operating rooms into intensive care units and the versatility of the physician anesthesiologist during the COVID-19 crisis. Clinics (Sao Paulo) 2020; 75:e2023. [PMID: 32555950 PMCID: PMC7279628 DOI: 10.6061/clinics/2020/e2023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Maria José Carvalho Carmona
- Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Vinícius Caldeira Quintão
- Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Brigite Feiner de Melo
- Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Guerson André
- Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rafael Priante Kayano
- Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Beatriz Perondi
- Diretoria Clinica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Anna Miethke-Morais
- Diretoria Clinica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marcelo Cristiano Rocha
- Departamento de Cirurgia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Marcelo Sá Malbouisson
- Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - José Otávio Costa Auler-Júnior
- Disciplina de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Silva Júnior JM, Chaves RCDF, Corrêa TD, Assunção MSCD, Katayama HT, Bosso FE, Amendola CP, Serpa Neto A, Malbouisson LMS, Oliveira NED, Veiga VC, Rojas SSO, Postalli NF, Alvarisa TK, Lucena BMND, Oliveira RAGD, Sanches LC, Silva UVDAE, Nassar Junior AP. Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil. Rev Bras Ter Intensiva 2020; 32:17-27. [PMID: 32401988 PMCID: PMC7206944 DOI: 10.5935/0103-507x.20200005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
Objective To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil. Methods This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated. Results Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051). Conclusion Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.
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Affiliation(s)
| | | | | | | | | | | | | | - Ary Serpa Neto
- Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | | | - Neymar Elias de Oliveira
- Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil
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20
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Figueiredo-Mello C, Casadio LVB, Avelino-Silva VI, Yeh-Li H, Sztajnbok J, Joelsons D, Antonio MB, Pinho JRR, Malta FDM, Gomes-Gouvêa MS, Salles APM, Corá AP, Moreira CHV, Ribeiro AF, Nastri ACDSS, Malaque CMS, Teixeira RFA, Borges LMS, Gonzalez MP, Junior LCP, Souza TNL, Song ATW, D'Albuquerque LAC, Abdala E, Andraus W, Martino RBD, Ducatti L, Andrade GM, Malbouisson LMS, Souza IMD, Carrilho FJ, Sabino EC, Levin AS. Efficacy of sofosbuvir as treatment for yellow fever: protocol for a randomised controlled trial in Brazil (SOFFA study). BMJ Open 2019; 9:e027207. [PMID: 31772079 PMCID: PMC6887076 DOI: 10.1136/bmjopen-2018-027207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION An ongoing outbreak of yellow fever (YF) has been reported in Brazil with 1261 confirmed cases and 409 deaths since July 2017. To date, there is no specific treatment available for YF. Recently published papers describing in vitro and animal models suggest a potential effect of antiviral drugs (approved for the treatment of hepatitis virus) against flaviviruses, including YF. The primary aim of this study is to analyse the effect of sofosbuvir on viral kinetics and clinical outcomes among patients presenting with YF. This is a multicentre open-label randomised controlled trial with 1:1 individual allocation, stratified by severity and by recruiting centre. METHODS AND ANALYSIS Adults with suspected or confirmed YF infection and symptoms lasting up to 15 days are screened. Eligible and consenting patients are randomised to receive oral sofosbuvir 400 mg daily for 10 days or to receive standard clinical care. Viral kinetics are measured daily and the reduction in YF plasma viral load from the sample at inclusion to 72 hours after randomisation will be compared between active and control groups. Clinical outcomes include severity meeting criteria for intensive care support, liver transplantation, in-hospital mortality and mortality within 60 days. ETHICS AND DISSEMINATION Ethics approval was obtained at the participating sites and at the national research ethics committee (CAAE 82673018.6.1001.0068). The trial has been submitted for ethical approval at additional potential recruiting centres. Results of the study will be published in journals and presented at scientific meetings. TRIAL REGISTRATION Brazilian Clinical Trials Registry (RBR-93dp9n).
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Affiliation(s)
- Claudia Figueiredo-Mello
- Department of Education and Research, Instituto de Infectologia Emilio Ribas, Sao Paulo, SP, Brazil
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Luciana Vilas Boas Casadio
- Department of Infectious and Parasitic Diseases, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Department of Gastroenterology (LIM07), Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Vivian Iida Avelino-Silva
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ho Yeh-Li
- Department of Infectious and Parasitic Diseases, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jaques Sztajnbok
- Medical Division-Intensive Care Unit, Instituto de Infectologia Emilio Ribas, Sao Paulo, SP, Brazil
| | - Daniel Joelsons
- Department of Infectious and Parasitic Diseases, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Marilia Bordignon Antonio
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - João Renato Rebello Pinho
- Department of Gastroenterology (LIM07), Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Fernanda de Mello Malta
- Department of Gastroenterology (LIM07), Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Michele Soares Gomes-Gouvêa
- Department of Gastroenterology (LIM07), Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Ana Paula Moreira Salles
- Department of Gastroenterology (LIM07), Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Aline Pivetta Corá
- Clinical Lab, Instituto de Infectologia Emilio Ribas, Sao Paulo, SP, Brazil
| | | | - Ana Freitas Ribeiro
- Epidemiology Service, Instituto de Infectologia Emilio Ribas, Sao Paulo, SP, Brazil
| | - Ana Catharina de Seixas Santos Nastri
- Department of Infectious and Parasitic Diseases, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Department of Gastroenterology (LIM07), Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | | | | | | | | | | | | | - Alice Tung Wan Song
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Edson Abdala
- Department of Infectious and Parasitic Diseases, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Infectious Diseases, Universidade de Sao Paulo Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, SP, Brazil
| | - Wellington Andraus
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Rodrigo Bronze de Martino
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Liliana Ducatti
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Guilherme Marques Andrade
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Izabel Marcilio de Souza
- Epidemiologic Surveillance Department, Universidade de São Paulo Hospital das Clínicas, Sao Paulo, SP, Brazil
| | - Flair José Carrilho
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ester Cerdeira Sabino
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Anna S Levin
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Brasil S, Bor-Seng-Shu E, de-Lima-Oliveira M, Taccone FS, Gattás G, Nunes DM, Gomes de Oliveira RA, Martins Tomazini B, Tierno PF, Becker RA, Bassi E, Sá Malbouisson LM, da Silva Paiva W, Teixeira MJ, de Carvalho Nogueira R. Computed tomography angiography accuracy in brain death diagnosis. J Neurosurg 2019; 133:1-9. [PMID: 31561215 DOI: 10.3171/2019.6.jns191107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/18/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The present study was designed to answer several concerns disclosed by systematic reviews indicating no evidence to support the use of computed tomography angiography (CTA) in the diagnosis of brain death (BD). Therefore, the aim of this study was to assess the effectiveness of CTA for the diagnosis of BD and to define the optimal tomographic criteria of intracranial circulatory arrest. METHODS A unicenter, prospective, observational case-control study was undertaken. Comatose patients (Glasgow Coma Scale score ≤ 5), even those presenting with the first signs of BD, were included. CTA scanning of arterial and venous vasculature and transcranial Doppler (TCD) were performed. A neurological determination of BD and consequently determination of case (BD group) or control (no-BD group) was conducted. All personnel involved with assessing patients were blinded to further tests results. Accuracy of BD diagnosis determined by using CTA was calculated based on the criteria of bilateral absence of visualization of the internal cerebral veins and the distal middle cerebral arteries, the 4-point score (4PS), and an exclusive criterion of absence of deep brain venous drainage as indicated by the absence of deep venous opacification on CTA, the venous score (VS), which considers only the internal cerebral veins bilaterally. RESULTS A total of 106 patients were enrolled in this study; 52 patients did not have BD, and none of these patients had circulatory arrest observed by CTA or TCD (100% specificity). Of the 54 patients with a clinical diagnosis of BD, 33 met the 4PS (61.1% sensitivity), whereas 47 met the VS (87% sensitivity). The accuracy of CTA was time related, with greater accuracy when scanning was performed less than 12 hours prior to the neurological assessment, reaching 95.5% sensitivity with the VS. CONCLUSIONS CTA can reliably support a diagnosis of BD. The criterion of the absence of deep venous opacification, which can be assessed by use of the VS criteria investigated in this study, can confirm the occurrence of cerebral circulatory arrest.Clinical trial registration no.: 12500913400000068 (clinicaltrials.gov).
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Affiliation(s)
| | | | | | | | | | | | | | - Bruno Martins Tomazini
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
| | - Paulo Fernando Tierno
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
| | - Rafael Akira Becker
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
| | - Estevão Bassi
- 3Trauma Intensive Care Unit, Hospital das Clinicas, School of Medicine, São Paulo, Brazil; and
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22
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Casadio LVB, Salles APM, Malta FDM, Leite GF, Ho YL, Gomes-Gouvêa MS, Malbouisson LMS, Levin AS, de Azevedo Neto RS, Carrilho FJ, Nastri ACSS, Pinho JRR. Lipase and factor V (but not viral load) are prognostic factors for the evolution of severe yellow fever cases. Mem Inst Oswaldo Cruz 2019; 114:e190033. [PMID: 31116245 PMCID: PMC6528381 DOI: 10.1590/0074-02760190033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 04/24/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite a highly efficacious vaccine, yellow fever (YF) is still a major threat in developing countries and a cause of outbreaks. In 2018, the Brazilian state of São Paulo witnessed a new YF outbreak in areas where the virus has not been detected before. OBJECTIVE The aim is to describe the clinical and laboratorial characteristics of severe cases of YF, evaluate viral to determine markers associated with fatal outcome. METHODS Acute severe YF cases (n = 62) were admitted to the Intensive Care Unit of a reference hospital and submitted to routine laboratorial evaluation on admission. YFV-RNA was detected in serum and urine by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and then sequenced. Patients were classified in two groups: survival or death. FINDINGS In the univariate analysis the following variables were associated with outcome: alanin aminotransferase (ALT), aspartat aminotransferase (AST), AST/ALT ratio, total bilirubin (TB), chronic kidney disease epidemiology collaboration (CKD-EPI), ammonia, lipase, factor V, international normalised ratio (INR), lactate and bicarbonate. Logistic regression model showed two independent variables associated with death: lipase [odds ratio (OR) 1.018, 95% confidence interval (CI) 1.007 to 1.030, p = 0.002], and factor V (OR -0.955, 95% CI 0.929 to 0.982, p = 0.001). The estimated lipase and factor V cut-off values that maximised sensitivity and specificity for death prediction were 147.5 U/L [area under the curve (AUC) = 0.879], and 56.5% (AUC = 0.913). MAIN CONCLUSIONS YF acute severe cases show a generalised involvement of different organs (liver, spleen, heart, kidneys, intestines and pancreas), and different parameters were related to outcome. Factor V and lipase are independent variables associated with death, reinforcing the importance of hemorrhagic events due to fulminant liver failure and pointing to pancreatitis as a relevant event in the outcome of the disease.
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Affiliation(s)
- Luciana Vilas Boas Casadio
- Universidade de São Paulo, Faculdade de Medicina da São Paulo, Instituto de Medicina Tropical, Departamento de Gastroenterologia, Laboratório de Gastroenterologia e Hepatologia Tropical - LIM/07, São Paulo, SP, Brasil.,Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, SP, Brasil
| | - Ana Paula Moreira Salles
- Universidade de São Paulo, Faculdade de Medicina da São Paulo, Instituto de Medicina Tropical, Departamento de Gastroenterologia, Laboratório de Gastroenterologia e Hepatologia Tropical - LIM/07, São Paulo, SP, Brasil
| | - Fernanda de Mello Malta
- Universidade de São Paulo, Faculdade de Medicina da São Paulo, Instituto de Medicina Tropical, Departamento de Gastroenterologia, Laboratório de Gastroenterologia e Hepatologia Tropical - LIM/07, São Paulo, SP, Brasil
| | - Gabriel Fialkovitz Leite
- Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, SP, Brasil
| | - Yeh-Li Ho
- Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, SP, Brasil
| | - Michele Soares Gomes-Gouvêa
- Universidade de São Paulo, Faculdade de Medicina da São Paulo, Instituto de Medicina Tropical, Departamento de Gastroenterologia, Laboratório de Gastroenterologia e Hepatologia Tropical - LIM/07, São Paulo, SP, Brasil
| | - Luiz Marcelo Sá Malbouisson
- Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Anna S Levin
- Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, SP, Brasil.,Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | | | - Flair José Carrilho
- Universidade de São Paulo, Faculdade de Medicina da São Paulo, Instituto de Medicina Tropical, Departamento de Gastroenterologia, Laboratório de Gastroenterologia e Hepatologia Tropical - LIM/07, São Paulo, SP, Brasil.,Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Ana Catharina Seixas Santos Nastri
- Universidade de São Paulo, Faculdade de Medicina da São Paulo, Instituto de Medicina Tropical, Departamento de Gastroenterologia, Laboratório de Gastroenterologia e Hepatologia Tropical - LIM/07, São Paulo, SP, Brasil.,Faculdade de Medicina da Universidade de São Paulo, Hospital das Clínicas, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, SP, Brasil
| | - João Renato Rebello Pinho
- Universidade de São Paulo, Faculdade de Medicina da São Paulo, Instituto de Medicina Tropical, Departamento de Gastroenterologia, Laboratório de Gastroenterologia e Hepatologia Tropical - LIM/07, São Paulo, SP, Brasil.,Hospital Israelita Albert Einstein, Albert Einstein Medicina Diagnóstica, Laboratório de Técnicas Especiais, São Paulo, SP, Brasil
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23
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Amendola CP, Silva-Jr JM, Carvalho T, Sanches LC, de Andrade e Silva UV, Almeida R, Burdmann E, Lima E, Barbosa FF, Ferreira RS, Carmona MJC, Malbouisson LMS, Nogueira FAM, Auler-Júnior JOC, Lobo SM. Goal-directed therapy in patients with early acute kidney injury: a multicenter randomized controlled trial. Clinics (Sao Paulo) 2018; 73:e327. [PMID: 30379222 PMCID: PMC6201149 DOI: 10.6061/clinics/2018/e327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/28/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Acute kidney injury is associated with many conditions, and no interventions to improve the outcomes of established acute kidney injury have been developed. We performed this study to determine whether goal-directed therapy conducted during the early stages of acute kidney injury could change the course of the disease. METHODS This was a multicenter prospective randomized controlled study. Patients with early acute kidney injury in the critical care unit were randomly allocated to a standard care (control) group or a goal-directed therapy group with 8h of intensive treatment to maximize oxygen delivery, and all patients were evaluated during a period of 72h. ClinicalTrials.gov: NCT02414906. RESULTS A total of 143 patients were eligible for the study, and 99 patients were randomized. Central venous oxygen saturation was significantly increased and the serum lactate level significantly was decreased from baseline levels in the goal-directed therapy group (p=0.001) compared to the control group (p=0.572). No significant differences in the change in serum creatinine level (p=0.96), persistence of acute kidney injury beyond 72h (p=0.064) or the need for renal replacement therapy (p=0.82) were observed between the two groups. In-hospital mortality was significantly lower in the goal-directed therapy group than in the control group (33% vs. 51%; RR: 0.61, 95% CI: 0.37-1.00, p=0.048, number needed to treat=5). CONCLUSIONS Goal-directed therapy for patients in the early stages of acute kidney injury did not change the disease course.
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Affiliation(s)
| | - João Manoel Silva-Jr
- Instituto de Assistencia Medica ao Servidor Publico Estadual, Hospital do Servidor Publico Estadual (HSPE), Sao Paulo, SP, BR
- Divisao de Anestesiologia e Terapia Intensiva Cirurgica, Instituto do Coracao (InCor), Divisao de Anestesiologia do Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | | | | | | | - Emmanuel Burdmann
- Divisao de Nefrologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Emerson Lima
- Faculdade de Medicina de Sao Jose do Rio Preto, Sao Jose do Rio Preto, SP, BR
| | | | | | - Maria José C Carmona
- Divisao de Anestesiologia e Terapia Intensiva Cirurgica, Instituto do Coracao (InCor), Divisao de Anestesiologia do Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Marcelo Sá Malbouisson
- Divisao de Anestesiologia e Terapia Intensiva Cirurgica, Instituto do Coracao (InCor), Divisao de Anestesiologia do Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fernando A M Nogueira
- Instituto de Assistencia Medica ao Servidor Publico Estadual, Hospital do Servidor Publico Estadual (HSPE), Sao Paulo, SP, BR
| | - José Otavio Costa Auler-Júnior
- Divisao de Anestesiologia e Terapia Intensiva Cirurgica, Instituto do Coracao (InCor), Divisao de Anestesiologia do Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Affiliation(s)
- Luiz Marcelo Sá Malbouisson
- Surgical Intensive Care Units, Hospital das Clínicas, Faculdade de
Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
- Discipline of Anesthesiology, Hospital das Clínicas, Faculdade de
Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
| | - Raphael Augusto Gomes de Oliveira
- Surgical Intensive Care Units, Hospital das Clínicas, Faculdade de
Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
- Intensive Care Unit, Hospital Sírio-Libanês - São Paulo (SP),
Brazil
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Malbouisson LMS, Silva JM, Carmona MJC, Lopes MR, Assunção MS, Valiatti JLDS, Simões CM, Auler JOC. A pragmatic multi-center trial of goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery. BMC Anesthesiol 2017; 17:70. [PMID: 28558654 PMCID: PMC5450107 DOI: 10.1186/s12871-017-0356-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 05/08/2017] [Indexed: 11/24/2022] Open
Abstract
Background Intraoperative fluid therapy guided by mechanical ventilation-induced pulse-pressure variation (PPV) may improve outcomes after major surgery. We tested this hypothesis in a multi-center study. Methods The patients were included in two periods: a first control period (control group; n = 147) in which intraoperative fluids were given according to clinical judgment. After a training period, intraoperative fluid management was titrated to maintain PPV < 10% in 109 surgical patients (PPV group). We performed 1:1 propensity score matching to ensure the groups were comparable with regard to age, weight, duration of surgery, and type of operation. The primary endpoint was postoperative hospital length of stay. Results After matching, 84 patients remained in each group. Baseline characteristics, surgical procedure duration and physiological parameters evaluated at the start of surgery were similar between the groups. The volume of crystalloids (4500 mL [3200-6500 mL] versus 5000 mL [3750-8862 mL]; P = 0.01), the number of blood units infused during the surgery (1.7 U [0.9-2.0 U] versus 2.0 U [1.7-2.6 U]; P = 0.01), the fraction of patients transfused (13.1% versus 32.1%; P = 0.003) and the number of patients receiving mechanical ventilation at 24 h (3.2% versus 9.7%; P = 0.027) were smaller postoperatively in PPV group. Intraoperative PPV-based improved the composite outcome of postoperative complications OR 0.59 [95% CI 0.35-0.99] and reduced the postoperative hospital length of stay (8 days [6-14 days] versus 11 days [7-18 days]; P = 0.01). Conclusions In high-risk surgeries, PPV-directed volume loading improved postoperative outcomes and decreased the postoperative hospital length of stay. Trial Registration ClinicalTrials.gov Identifier; retrospectively registered- NCT03128190
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Affiliation(s)
- Luiz Marcelo Sá Malbouisson
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil.
| | - João Manoel Silva
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | - Maria José Carvalho Carmona
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | - Marcel Rezende Lopes
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | | | | | - Claudia Marques Simões
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
| | - José Otavio Costa Auler
- Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil
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Silva JM, Rocha HMC, Katayama HT, Dias LF, de Paula MB, Andraus LMR, Silva JMC, Malbouisson LMS. SAPS 3 score as a predictive factor for postoperative referral to intensive care unit. Ann Intensive Care 2016; 6:42. [PMID: 27130426 PMCID: PMC4851671 DOI: 10.1186/s13613-016-0129-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 03/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients undergoing intermediate-risk surgery are typically taken to the ward postoperatively. However, some may develop complications requiring intensive care later. We aimed to evaluate the characteristics of patients undergoing intermediate-risk surgery who required late postoperative admission to the intensive care unit (ICU) and determine the predictors for this. METHODS The study included patients undergoing intermediate-risk surgery with preoperative indication for ICU but who were taken to the ward postoperatively, because they appeared to be responding well. However, they required late ICU admission. ICU care and preoperative SAPS 3 score were evaluated. Palliative surgeries and patients readmitted to ICU were excluded. RESULTS The study included 100 patients, 27 % of whom had late postoperative admission to the ICU. The preoperative SAPS 3 score was higher (45.4 ± 7.8 vs. 35.9 ± 7.4, P < 0.001) in patients who required delayed admission to the ICU postoperatively. Furthermore, they had undergone longer surgery (4.2 ± 1.9 vs. 2.7 ± 1.5 h, P < 0.001), and a greater proportion were gastrointestinal surgeries (14.8 vs. 5.5 %, P = 0.03) and intraoperative transfusion (18.5 vs. 5.5 % P = 0.04). In multivariate analysis, preoperative SAPS 3 and surgery duration independently predicted postoperative ICU admission, respectively (OR 1.25; 95 % CI 1.1-1.4 and OR 3.33; 95 % CI 1.7-6.3). CONCLUSION The identification of high-risk surgical patients is essential for proper treatment; time of surgery and preoperative SAPS 3 seem to provide a useful indication of risk and may help better to characterize patients undergoing intermediate-risk surgery that demand ICU care.
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Affiliation(s)
- João M. Silva
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
- Anaesthesiology Department, Hospital das Clinicas SP-FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 Cerqueira César, São Paulo, SP 05403-000 Brazil
| | - Helder Marcus Costa Rocha
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
| | - Henrique Tadashi Katayama
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
| | - Leandro Ferreira Dias
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
| | - Mateus Barros de Paula
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
| | - Leusi Magda Romano Andraus
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
| | - Jose Maria Correa Silva
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
| | - Luiz Marcelo Sá Malbouisson
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A–Vila Clementino, São Paulo, SP 04039-901 Brazil
- Anaesthesiology Department, Hospital das Clinicas SP-FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 Cerqueira César, São Paulo, SP 05403-000 Brazil
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Silva JM, Rocha HMC, Katayama HT, Dias LF, de Paula MB, Andraus LMR, Silva JMC, Malbouisson LMS. Erratum to: SAPS 3 score as a predictive factor for postoperative referral to intensive care unit. Ann Intensive Care 2016; 6:78. [PMID: 27530129 PMCID: PMC4987742 DOI: 10.1186/s13613-016-0180-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/21/2016] [Indexed: 11/27/2022] Open
Affiliation(s)
- João M Silva
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil. .,Anaesthesiology Department, Hospital das Clinicas SP-FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Helder Marcus Costa Rocha
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil
| | - Henrique Tadashi Katayama
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil
| | - Leandro Ferreira Dias
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil
| | - Mateus Barros de Paula
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil
| | - Leusi Magda Romano Andraus
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil
| | - Jose Maria Correa Silva
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Hospital Servidor Publico Estadual-SP, Rua Pedro de Toledo, 1800/6º A-Vila Clementino, São Paulo, SP, 04039-901, Brazil.,Anaesthesiology Department, Hospital das Clinicas SP-FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 Cerqueira César, São Paulo, SP, 05403-000, Brazil
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Franco SS, Malbouisson LMS, Grinberg M, Feltrim MIZ. A propose of pulmonary dysfunction stratification after valve surgery by physiotherapeutic assistance level. Braz J Cardiovasc Surg 2016; 30:188-97. [PMID: 26107450 PMCID: PMC4462964 DOI: 10.5935/1678-9741.20150006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/26/2015] [Indexed: 11/20/2022] Open
Abstract
Objective a) to propose and implement an evaluation system; b) to classify the
pulmonary involvement and determine levels of physical therapy; c) to check
the progress postoperatively. Methods Patients underwent physiotherapy assessment preoperatively, postoperatively
and after 5 days of intervention. They were classified into three levels of
care: level 1 - low risk of complication; Level 2 - medium risk; Level 3 -
high risk. We used analysis of variance and Kruskal-Wallis and analysis of
variance for repeated measures or Friedman. Chi-square test or Fisher for
proportions. We considered statistical significance level
P<0.05. Results We studied 199 patients, 156 classified within level 1, 32 at level 2 and 11
at level 3. Thoracoabdominal motion and auscultation changed significantly
postoperatively, persisting at levels 2 and 3 (P<0.05).
Oxygenation and respiratory rate changed at levels 2 and 3 postoperatively
(P<0.05) with recovery at the end. Significant
decrease in lung volumes occurred in three levels
(P<0.05) with partial recovery at level 1, lung collapse
occurred at all levels, with recovery by 56% at level 1, 47% at level 2, 27%
at level 3. Conclusion The proposed assessment identified valve surgery patients who require
differentiated physical therapy. Level 1 patients had rapid recovery, while
the level 2 showed significant changes with functional gains at the end.
Level 3 patients, more committed and prolonged recovery, should receive
greater assistance.
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Affiliation(s)
- Satiko Shimada Franco
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Max Grinberg
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Pereira VR, Azuma RA, Gatto BEO, Silva Junior JM, Carmona MJC, Malbouisson LMS. [Hyperglycemia assessment in the post-anesthesia care unit]. Rev Bras Anestesiol 2016; 67:565-570. [PMID: 27005828 DOI: 10.1016/j.bjan.2015.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 08/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hyperglycemia in surgical patients may cause serious problems. Analyzing this complication in this scenario contributes to improve the management of these patients. The aim of this study was to evaluate the prevalence of hyperglycemia in the post-anesthetic care unit (PACU) in non-diabetic patients undergoing elective surgery and analyze the possible risk factors associated with this complication. METHODS We evaluated non-diabetic patients undergoing elective surgeries and admitted in the PACU. Data were collected from medical records through precoded questionnaire. Hyperglycemia was considered when blood glucose was>120mg.dL-1. Patients with hyperglycemia were compared to normoglycemic ones to assess factors associated with the problem. We excluded patients with endocrine-metabolic disorders, diabetes, children under 18 years, body mass index (BMI) below 18 or above 35, pregnancy, postpartum or breastfeeding, history of drug use, and emergency surgeries. RESULTS We evaluated 837 patients. The mean age was 47.8±16.1 years. The prevalence of hyperglycemia in the postoperative period was 26.4%. In multivariate analysis, age (OR=1.031, 95% CI 1.017-1.045); BMI (OR=1.052, 95% CI 1.005-1.101); duration of surgery (OR=1.011, 95% CI 1.008-1.014), history of hypertension (OR=1.620, 95% CI 1.053-2.493), and intraoperative use of corticosteroids (OR=5.465, 95% CI 3.421-8.731) were independent risk factors for postoperative hyperglycemia. CONCLUSION The prevalence of hyperglycemia was high in the PACU, and factors such as age, BMI, corticosteroids, blood pressure, and duration of surgery are strongly related to this complication.
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Affiliation(s)
- Vinicius Rodovalho Pereira
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Rodrigo Akio Azuma
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Bruno Emanuel Oliva Gatto
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - João Manoel Silva Junior
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil.
| | - Maria Jose Carvalho Carmona
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
| | - Luiz Marcelo Sá Malbouisson
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil
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Bassi E, Miranda LC, Tierno PFGMM, Ferreira CB, Cadamuro FM, Figueiredo VR, Damasceno MCDT, Malbouisson LMS. Assistance of inhalation injury victims caused by fire in confined spaces: what we learned from the tragedy at Santa Maria. Rev Bras Ter Intensiva 2016; 26:421-9. [PMID: 25607274 PMCID: PMC4304473 DOI: 10.5935/0103-507x.20140065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 10/28/2014] [Indexed: 11/30/2022] Open
Abstract
On January 2013, a disaster at Santa Maria (RS) due to a fire in a confined space
caused 242 deaths, most of them by inhalation injury. On November 2013, four
individuals required intensive care following smoke inhalation from a fire at the
Memorial da América Latina in São Paulo (SP). The
present article reports the clinical progression and management of disaster victims
presenting with inhalation injury. Patients ERL and OC exhibited early respiratory
failure, bronchial aspiration of carbonaceous material, and carbon monoxide
poisoning. Ventilation support was performed with 100% oxygen, the aspirated material
was removed by bronchoscopy, and cyanide poisoning was empirically treated with
sodium nitrite and sodium thiosulfate. Patient RP initially exhibited cough and
retrosternal burning and subsequently progressed to respiratory failure due to upper
airway swelling and early-onset pulmonary infection, which were treated with
protective ventilation and antimicrobial agents. This patient was extubated following
improvement of edema on bronchoscopy. Patient MA, an asthmatic, exhibited carbon
monoxide poisoning and bronchospasm and was treated with normobaric hyperoxia,
bronchodilators, and corticosteroids. The length of stay in the intensive care unit
varied from four to 10 days, and all four patients exhibited satisfactory functional
recovery. To conclude, inhalation injury has a preponderant role in fires in confined
spaces. Invasive ventilation should not be delayed in cases with significant airway
swelling. Hyperoxia should be induced early as a therapeutic means against carbon
monoxide poisoning, in addition to empiric pharmacological treatment in suspected
cases of cyanide poisoning.
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Affiliation(s)
- Estevão Bassi
- Unidade de Terapia Intensiva de Emergência Cirúrgica e Trauma, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Leandro Costa Miranda
- Unidade de Terapia Intensiva de Emergência Cirúrgica e Trauma, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - César Biselli Ferreira
- Unidade de Terapia Intensiva de Emergência Cirúrgica e Trauma, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Filipe Matheus Cadamuro
- Unidade de Terapia Intensiva de Emergência Cirúrgica e Trauma, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Viviane Rossi Figueiredo
- Departamento de Broncoscopia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Luiz Marcelo Sá Malbouisson
- Unidade de Terapia Intensiva de Emergência Cirúrgica e Trauma, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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da Luz VF, Otsuki DA, Gonzalez MMC, Negri EM, Caldini EG, Damaceno-Rodrigues NR, Malbouisson LMS, Viana BG, Vane MF, Carmona MJC. Myocardial protection induced by fentanyl in pigs exposed to high-dose adrenaline. Clin Exp Pharmacol Physiol 2015; 42:1098-107. [DOI: 10.1111/1440-1681.12456] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 01/02/2023]
Affiliation(s)
| | - Denise Aya Otsuki
- University of Sao Paulo Medical School; Department of Anaesthesiology; São Paulo Brazil
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Barbas CSV, Ísola AM, Farias AMDC, Cavalcanti AB, Gama AMC, Duarte ACM, Vianna A, Serpa A, Bravim BDA, Pinheiro BDV, Mazza BF, de Carvalho CRR, Toufen C, David CMN, Taniguchi C, Mazza DDDS, Dragosavac D, Toledo DO, Costa EL, Caser EB, Silva E, Amorim FF, Saddy F, Galas FRBG, Silva GS, de Matos GFJ, Emmerich JC, Valiatti JLDS, Teles JMM, Victorino JA, Ferreira JC, Prodomo LPDV, Hajjar LA, Martins LC, Malbouisson LMS, Vargas MADO, Reis MAS, Amato MBP, Holanda MA, Park M, Jacomelli M, Tavares M, Damasceno MCP, Assunção MSC, Damasceno MPCD, Youssef NCM, Teixeira PJZ, Caruso P, Duarte PAD, Messeder O, Eid RC, Rodrigues RG, de Jesus RF, Kairalla RA, Justino S, Nemer SN, Romero SB, Amado VM. Brazilian recommendations of mechanical ventilation 2013. Part I. Rev Bras Ter Intensiva 2015; 26:89-121. [PMID: 25028944 PMCID: PMC4103936 DOI: 10.5935/0103-507x.20140017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Carmen Sílvia Valente Barbas
- Corresponding author: Carmen Silvia Valente Barbas, Disicplina de
Pneumologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São
Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, Zip code - 05403-900 - São Paulo
(SP), Brazil. E-mail:
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Gobatto ALN, Besen BAMP, Tierno PFGMM, Mendes PV, Cadamuro F, Joelsons D, Melro L, Park M, Malbouisson LMS. Ultrasound-guided percutaneous dilatational tracheostomy: going deep into the sea. J Crit Care 2014; 30:427-8. [PMID: 25499418 DOI: 10.1016/j.jcrc.2014.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 11/24/2014] [Indexed: 11/17/2022]
Affiliation(s)
- André Luiz Nunes Gobatto
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Surgical Intensive Care Unit, Anesthesiology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
| | | | | | - Pedro Vitale Mendes
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Filipe Cadamuro
- Trauma Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Joelsons
- Intensive Care Unit, Infectious Disease Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Livia Melro
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcelo Park
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Trauma Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Surgical Intensive Care Unit, Anesthesiology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Ida KK, Malbouisson LMS, Otsuki DA, Chisholm KI, Dyson A, Singer M, Duchen MR, Smith KJ. 0036. Confocal imaging of impaired mitochondrial function in the cerebral cortex of rats during haemorrhagic shock in vivo. Intensive Care Med Exp 2014. [PMCID: PMC4797095 DOI: 10.1186/2197-425x-2-s1-o9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Gobatto ALN, Besen BAMP, Tierno PFGMM, Mendes PV, Cadamuro F, Joelsons D, Melro L, Park M, Malbouisson LMS. Comparison between ultrasound- and bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients: a retrospective cohort study. J Crit Care 2014; 30:220.e13-7. [PMID: 25306240 DOI: 10.1016/j.jcrc.2014.09.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/13/2014] [Accepted: 09/14/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Percutaneous dilational tracheostomy (PDT) is routinely performed in the intensive care unit with bronchoscopic guidance. Recently, ultrasound (US) has emerged as a new safety adjunct tool to increase the efficacy of PDT. However, the available data are limited to case series without any control group. Hence, a retrospective cohort study was designed to evaluate the efficacy of US-guided PDT compared with bronchoscopy-guided PDT. METHODS All patients who were submitted to PDT after the standardization of US-guided PDT technique in our institution were analyzed. Demographic and procedure-related variables, complications, and clinical outcomes were collected and compared in patients undergoing US- or bronchoscopy-guided PDT. RESULTS Sixty patients who had been submitted to PDT were studied, including 11 under bronchoscopy guidance and 49 under US guidance. No surgical conversion was necessary in any of the procedures, and bronchoscopy assistance was only required in 1 case in the US group. The procedure length was shorter in the US group than in the bronchoscopy group (12 vs 15 minutes, P = .028). None of the patients had any major complications. The minor complication rates were not significantly different between the groups, nor was the probability of breathing without assistance within 28 days, intensive care unit length of stay, or hospital mortality. CONCLUSION Ultrasound-guided PDT is effective, safe, and associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided PDT.
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Affiliation(s)
- André Luiz Nunes Gobatto
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Surgical Intensive Care Unit, Anesthesiology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
| | | | | | - Pedro Vitale Mendes
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Filipe Cadamuro
- Trauma Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Joelsons
- Intensive Care Unit, Infectious Disease Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Livia Melro
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcelo Park
- Medical Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Trauma Intensive Care Unit, Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Surgical Intensive Care Unit, Anesthesiology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Silva JM, Barros MA, Chahda MAL, Santos IM, Marubayashi LY, Malbouisson LMS. Risk factors for perioperative complications in endoscopic surgery with irrigation. Braz J Anesthesiol 2014; 63:327-33. [PMID: 24565239 DOI: 10.1016/j.bjane.2012.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 07/02/2012] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Currently, endoscopic medicine is being increasingly used, albeit not without risks. Therefore, this study evaluated the factors associated with perioperative complications in endoscopic surgery with intraoperative irrigation. METHOD A cohort study of six months duration. Patients aged ≥ 18 years undergoing endoscopic surgery with the use of irrigation fluids during the intraoperative period were included. Exclusion criteria were: use of diuretics, kidney failure, cognitive impairment, hyponatremia prior to surgery, pregnancy, and critically ill. The patients who presented with or without complications during the perioperative period were allocated into two groups. Complications evaluated were related to neurological, cardiovascular and renal changes, and perioperative bleeding. RESULTS In total, 181 patients were enrolled and 39 excluded; therefore, 142 patients met the study criteria. Patients with complications amounted to 21.8%, with higher prevalence in endoscopic prostate surgery, followed by hysteroscopy, bladder, knee, and shoulder arthroscopy (58.1%, 36.9%, 19.4%, 3.8%, 3.2% respectively). When comparing both groups, we found association with complications in univariate analysis: age, sex, smoking, heart disease, ASA, serum sodium at the end of surgery, total irrigation fluid administered, TURP, and hysteroscopy. However, in multiple regression analysis for complications, only age (OR = 1.048), serum sodium (OR = 0.962), and volume of irrigation fluid administered during surgery (OR = 1.001) were independent variables. CONCLUSION The incidence of serious complications in endoscopic surgeries is high. Serum sodium at the end of the operation, amount of irrigation fluid, and age were strong independent factors associated with the problem. Thus, these factors must be taken into account in these surgeries.
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Affiliation(s)
- João Manoel Silva
- TSA; Coordinator of the Surgery Unit for Critically Ill Patients, Hospital do Servidor Público Estadual (HSPE); Co-responsible for the Center for Teaching and Training (CET)/Brazilian Society of Anesthesiology (SBA), HSPE; Science Reviewer of the Intensive Care Unit, HSPE; Master in Medical Sciences, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | | | | | | | - Lauro Yoiti Marubayashi
- Anesthesiologist; Director of the Anesthesiology Service, Perioperative Medicine, Intensive Pain and Therapy, S/S Ltda - SAMMEDI, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- TSA; Coordinator of the Surgical ICU Anesthesia Division of Hospital das Clinicas, FMUSP; Coordinator of the Surgery Unit for Critically Ill Patients, HSPE; PhD in Medical Sciences, FMUSP, São Paulo, Brazil
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Fraga AO, Malbouisson LMS, Prist R, Rocha E Silva M, Auler Júnior JOC. [Anesthetic induction after treated hemorrhagic shock: experimental study comparing ketamine and etomidate.]. Rev Bras Anestesiol 2012; 56:377-90. [PMID: 19468583 DOI: 10.1590/s0034-70942006000400006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Accepted: 04/28/2006] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Bleeding causing hemorrhagic shock usually requires surgical treatment under general anesthesia. Anesthetic drugs may further compromise hemodynamics. The objective was to compare the hemodynamic effects of ketamine and etomidate during anesthetic induction in dogs submitted to an experimental model of hemorrhagic shock and resuscitation. METHODS Thirty-two mongrel dogs were submitted to a pressure-controlled hemorrhagic shock, resuscitation and anesthetic induction model. After achieving the target pressure of 40 mmHg, they were randomly assigned in two groups according to the resuscitation fluid to be used: NaCl 0.9% (32 mL.kg-1) and NaCl 7.5% (4 mL.kg-1). After volume infusion, these groups were reassigned according to anesthetic drug used: GI) NaCl 0.9% and ketamine; GII) NaCl 7.5% and ketamine; GIII) NaCl 0.9% and etomidate; and GIV) NaCl 7.5% and etomidate. Hemodynamic measurements were obtained at five moments: (M0) baseline; (M1) after bleeding to shock; (M2) after volume expansion; (M3) 5 minutes after anesthetic induction; (M4) 15 minutes after anesthetic induction. Statistical analysis was performed using Student t test and two way ANOVA. Value of p lower than 0.05, was considered significant. RESULTS After shock, both solutions restored hemodynamics to baseline values. Independently of anesthetic agent or expansion solution used, mean arterial pressure remained unaltered for all groups after induction. Central venous pressure, heart rate, pulmonary capillary wedge pressure and pulmonary vascular resistance index increased significantly after ketamine infusion. Cardiac index, systemic vascular resistance index and oxygen transport variables remained stable in all groups. CONCLUSIONS Etomidate or ketamine were able to maintain hemodynamic stability in dogs undergoing severe hemorrhagic shock treated with NaCl 0.9% or NaCl 7.5%.
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Barbosa RAG, Malbouisson LMS, dos Santos LM, Piccioni MDA, Carmona MJC. Extracorporeal circulation interference on emergence from anesthesia in patients submitted to myocardial revascularization. Rev Bras Anestesiol 2012; 62:289-97. [PMID: 22656675 DOI: 10.1016/s0034-7094(12)70130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 08/03/2011] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Extracorporeal circulation (ECC) may change drug pharmacokinetics as well as brain function. The objectives of this study are to compare emergence time and postoperative sedation intensity assessed by the bispectral index (BIS) and the Ramsay sedation scale in patients undergoing myocardial revascularization (MR) with or without ECC. METHOD Ten patients undergoing MR with ECC (ECC group) and 10 with no ECC (no-ECC group) were administered with sufentanyl, propofol 2.0 μg.mL(-1) and pancuronium target controlled infusion. After surgery, propofol infusion was reduced to 1 μg.mL(-1) and suspended when extubation was indicated. Patients BIS, Ramsay scale and time to wake up were assessed. RESULTS The ECC group showed lower BIS values beginning at 60 minutes after surgery (no-ECC = 66±13 and ECC = 53±14, p=0.01) until 120 minutes after infusion (no-ECC = 85±8 and ECC = 73±12, p=0.02). Sedation level measured by the Ramsay scale was higher in the ECC group at 30 minutes after the end of the surgery (no-ECC = 5±1 and ECC = 6±0, p=0.021), at the end of infusion (no-ECC = 5±1 and ECC = 6±1, p=0.012) and 5 minutes after the end of infusion (no-ECC = 4±1 and ECC = 5±0.42, p=0.039). Emergence from anesthesia time was higher in the ECC group (no-ECC = 217±81 and ECC = 319±118, p=0.038). CONCLUSIONS There was a higher intensity of sedation after the end of surgery and a longer wake up time in ECC group, suggesting changes in the pharmacokinetics of propofol or effects of ECC on central nervous system.
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Barbosa RAG, Malbouisson LMS, Santos LMD, Piccioni MDA, Carmona MJC. Interferência da circulação extracorpórea no despertar da anestesia de pacientes submetidos à revascularização do miocárdio. Rev Bras Anestesiol 2012. [DOI: 10.1590/s0034-70942012000300002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Bassi E, Azevedo LCP, Costa ELV, Maciel AT, Vasconcelos E, Ferreira CB, Malbouisson LMS, Park M. Hemodynamic and respiratory support using venoarterial extracorporeal membrane oxygenation (ECMO) in a polytrauma patient. Rev Bras Ter Intensiva 2011; 23:374-379. [PMID: 23949411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 08/18/2011] [Indexed: 06/02/2023] Open
Abstract
There are few reports in the literature regarding the use of venoarterial extracorporeal membrane oxygenation (ECMO) for double-dysfunction from both heart and lung contusions in polytrauma patients. This article reports a 48-year-old patient admitted after a traffic accident. He rapidly progressed to shock with low cardiac output due to myocardial contusion and refractory hypoxemia due to pulmonary contusion, an unstable chest wall and bilateral pneumothorax. ECMO was an effective rescue procedure in this dramatic situation and was successfully discontinued on the fourth day after the trauma. The patient also developed an extensive brain infarction and eventually died on the seventh day after admission.
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Bassi E, Azevedo LCP, Costa ELV, Maciel AT, Vasconcelos E, Ferreira CB, Malbouisson LMS, Park M. Uso de suporte hemodinâmico e respiratório por meio de oxigenação extracorpórea por membrana (ECMO) venoarterial em um paciente politraumatizado. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000300017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kim SM, Malbouisson LMS, Auler Jr JOC, Carmona MJC. Alterações hemodinâmicas durante a revascularização do miocárdio sem utilização de circulação extracorpórea. Rev Bras Anestesiol 2011. [DOI: 10.1590/s0034-70942011000400005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Kim SM, Malbouisson LMS, Auler JOC, Carmona MJC. Hemodynamic changes during myocardial revascularization without extracorporeal circulation. Rev Bras Anestesiol 2011; 61:434-46. [PMID: 21724006 DOI: 10.1016/s0034-7094(11)70051-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 01/04/2011] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cardiac positioning and stabilization during myocardial revascularization without extracorporeal circulation (ECC) may cause hemodynamic changes dependent to the surgical site. The objective of this study was to evaluate these changes during distal coronary anastomosis. METHODS Twenty adult patients undergoing myocardial revascularization without ECC were monitored by pulmonary artery catheter and transesophageal Echo Doppler. Hemodynamic data were collected at the following times before removing the stabilizer wall: (1) after volume adjustments, (2) at the beginning of distal anastomosis, and (3) after 5 minutes. Treated coronary arteries were grouped according to their location in the lateral, anterior, or posterior wall. Two-way ANOVA with repetition and Newman-Keuls post-test were used in the analysis. A p value < 0.05 was considered statically significant. RESULTS During myocardial revascularization without ECC, pulmonary artery wedge pressure showed elevation from 17.7 ± 6.1 to 19.2 ± 6.5 (p < 0.001) and 19.4 ± 5.9 mmHg (p < 0.001), while the central venous pressure went from 13.9 ± 5.4 to 14.9 ± 5.9 mmHg (p = 0.007) and 15.1 ± 6.0 mmHg (p = 0.006). Intermittent cardiac output was reduced from 4.70 ± 1.43 to 4.23 ± 1.22 (p < 0.001) and 4.26 ± 1.25 L.min(-1) (p < 0.001). According to transesophageal Doppler, a significant group-time interaction was observed in cardiac output, which was reduced in the lateral group from 4.08 ± 1.99 to 2.84 ± 1.82 (p = 0.02) and 2.86 ± 1.73 L.min(-1) (p = 0.02), and aortic blood flow, which went from 2.85 ± 1.39 to 1.99 ± 1.26 (p = 0.02) and 2.00 ± 1.21 L.min(-1) (p = 0.02). Other hemodynamic changes were not observed during anastomoses. CONCLUSIONS A significant hemodynamic deterioration was observed during myocardial revascularization without ECC. Transesophageal Doppler detected a decrease in cardiac output only in the lateral group.
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Affiliation(s)
- Silvia Minhye Kim
- Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, Brazil.
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Rodrigues RR, Sawada AY, Rouby JJ, Fukuda MJ, Neves FH, Carmona MJ, Pelosi P, Auler JO, Malbouisson LMS. Computed tomography assessment of lung structure in patients undergoing cardiac surgery with cardiopulmonary bypass. Braz J Med Biol Res 2011; 44:598-605. [PMID: 21519640 DOI: 10.1590/s0100-879x2011007500048] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 03/16/2011] [Indexed: 11/21/2022] Open
Abstract
Hypoxemia is a frequent complication after coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB), usually attributed to atelectasis. Using computed tomography (CT), we investigated postoperative pulmonary alterations and their impact on blood oxygenation. Eighteen non-hypoxemic patients (15 men and 3 women) with normal cardiac function scheduled for CABG under CPB were studied. Hemodynamic measurements and blood samples were obtained before surgery, after intubation, after CPB, at admission to the intensive care unit, and 12, 24, and 48 h after surgery. Pre- and postoperative volumetric thoracic CT scans were acquired under apnea conditions after a spontaneous expiration. Data were analyzed by the paired Student t-test and one-way repeated measures analysis of variance. Mean age was 63 ± 9 years. The PaO2/FiO2 ratio was significantly reduced after anesthesia induction, reaching its nadir after CPB and partially improving 12 h after surgery. Compared to preoperative CT, there was a 31% postoperative reduction in pulmonary gas volume (P < 0.001) while tissue volume increased by 19% (P < 0.001). Non-aerated lung increased by 253 ± 97 g (P < 0.001), from 3 to 27%, after surgery and poorly aerated lung by 72 ± 68 g (P < 0.001), from 24 to 27%, while normally aerated lung was reduced by 147 ± 119 g (P < 0.001), from 72 to 46%. No correlations (Pearson) were observed between PaO2/FiO2 ratio or shunt fraction at 24 h postoperatively and postoperative lung alterations. The data show that lung structure is profoundly modified after CABG with CPB. Taken together, multiple changes occurring in the lungs contribute to postoperative hypoxemia rather than atelectasis alone.
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Affiliation(s)
- R R Rodrigues
- Divisão de Anestesia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Av. Enéas C. Aguiar 25, São Paulo, SP, Brazil
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Silva JM, Oliveira AMRR, Maia VP, Ferreira AMP, Toledo DO, Rezende E, Malbouisson LMS. Large venous-arterial PCO2 is associated with poor outcomes in surgical patients. Crit Care 2011. [PMCID: PMC3124212 DOI: 10.1186/cc10210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Carmona MJC, Martins LM, Vane MF, Longo BA, Paredes LS, Malbouisson LMS. Comparison of the effects of dobutamine and milrinone on hemodynamic parameters and oxygen supply in patients undergoing cardiac surgery with low cardiac output after anesthetic induction. Rev Bras Anestesiol 2011; 60:237-46. [PMID: 20682156 DOI: 10.1016/s0034-7094(10)70032-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 01/20/2010] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Several classes of inotropic drugs with different hemodynamic effects are used in the treatment of low cardiac output in patients with diastolic dysfunction undergoing cardiac surgery. The objective of the present study was to compare the effects of dobutamine and milrinone on hemodynamic parameters and oxygen supply in this population of patients. METHODS After approval by the Ethics Committee of the institution and signing of the informed consent, 20 patients undergoing cardiac surgery with cardiac index < 2 L*min(-1)*m(2) after anesthetic induction and placement of a pulmonary artery catheter were randomly divided to receive dobutamine 5 microg*kg(-1). min(-1) (n = 10), or milrinone 0.5 microg*kg(-1)*min(-1) (n = 10). Hemodynamic parameters were measured after anesthetic induction and after 30 and 60 minutes, and arterial and venous blood gases were measured at baseline and 60 minutes. Non-paired Student t test or two-way ANOVA for repeated measurements was used to compare the data. RESULTS Dobutamine and milrinone promoted significant increases in cardiac index (56% and 47%) and oxygen supply (53% and 45%), and reduction in systemic (33% and 36%) and pulmonary (34% and 19%) vascular resistance, respectively. However, statistically significant differences were not observed between both drugs. CONCLUSIONS Both inotropic drugs were similarly effective in restoring tissue blood flow and oxygen supply to adequate levels in patients with low cardiac output undergoing cardiac surgery.
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Barbosa RAG, Silva CDD, Torniziello MYT, Cerri LMDO, Carmona MJC, Malbouisson LMS. Estudo comparativo entre três técnicas de anestesia geral para biópsia de próstata dirigida por ultrassonografia transretal. Rev Bras Anestesiol 2010. [DOI: 10.1590/s0034-70942010000500002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Barbosa RAG, da Silva CD, Torniziello MYT, Cerri LMDO, Carmona MJC, Malbouisson LMS. A comparative study among three techniques of general anesthesia for ultrasound-guided transrectal prostate biopsy. Rev Bras Anestesiol 2010; 60:457-65. [PMID: 20863926 DOI: 10.1016/s0034-7094(10)70057-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 05/03/2010] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Ultrasound-guided transrectal prostate biopsy is a reference in the diagnosis of prostate neoplasias. The higher the number of samples, the greater is the pain and discomfort. The objective of this study was to compare three anesthetic techniques in this group of patients. METHODS Forty-five patients were included in this study. Patients were divided into three groups: 1 - Propofol; 2 - Propofol + Prostatic Plexus Block; 3 - Propofol + Fentanyl. Patients were monitored with non-invasive blood pressure, continuous electrocardioscopy, pulse oximetry (SpO₂), and Bispectral Index. Patients did not receive pre-anesthetic medication. Intraoperative and postoperative hemodynamic parameters, intraoperative bispectral index, and postoperative visual analogue scale (VAS) and the use of dypirone to treat postoperative pain were evaluated. RESULTS A significant difference among the three groups was not observed for: anthropometric parameters, amount of propofol, number of fragments, and duration of the exam. Hemodynamic parameters and SpO₂ presented similar behavior in all three groups. In group 1, the pain evaluated by the VAS was more severe and required more dypirone than in the other groups. CONCLUSIONS Sedation with propofol alone for biopsy is associated with greater postoperative pain and discomfort than in prostatic plexus block or systemic fentanyl. Besides hypnosis, intraoperative analgesia is required to guarantee postoperative comfort.
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Malbouisson LMS, de Souza ELS, Barbalho L, Massoco CDO, Carmona MJC, Auler JOC. Assessing the impact of lung hyperinflation maneuver on systemic inflammatory response and lung collapse in patients undergoing surgeries under spontaneous ventilation. Rev Bras Anestesiol 2010; 60:247-58. [PMID: 20682157 DOI: 10.1016/s0034-7094(10)70033-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 01/20/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Lung hyperinflation maneuvers (LHM) reverse intraoperative atelectasis; however, they can lead to pulmonary-induced systemic inflammatory response. The objective of this study was to determine the impact of LHM on systemic inflammatory response and lung structure in patients undergoing subarachnoid block. METHODS After approval by the Ethics Committee of the institution and signing the informed consent, 20 patients undergoing small and medium surgical procedures were randomly separated into two groups: 1) control (CG), and 2) LHM (LHMG). One hour after the spinal anesthesia, LHM was performed in LHMG by applying bilevel positive pressure in the airways (BIPAP) with an expiratory pressure of 20 cmH(2)O and inspiratory pressure of 20 cmH(2)O for 1 to 2 minutes. Blood levels of TNFalpha, IL-1, IL-6, IL-8, IL-10, and IL-12 were determined by flow cytometry at baseline and at 90, 180, and 780 minutes. Lung volumes and weights were determined using CT scans obtained immediately after the surgery. RESULTS The use of LHM resulted in a reduction in the fraction of non-aerated pulmonary parenchyma (7.5 +/- 4.3%, in the Control Group, vs. 4 +/- 2.1%, in the LHM Group, p = 0.02) without changing pulmonary volumes. A progressive increase in plasma levels of IL-1, IL-6, IL-8, and IL-10, similar in both groups, was observed. Plasma levels of TNFalpha and IL-12 were undetectable during the study. CONCLUSIONS The use of LHM reduced the incidence of atelectasis, but it did not amplify the inflammatory response in patients with normal lungs undergoing small and medium surgeries under subarachnoid block.
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Affiliation(s)
- Luiz Marcelo Sá Malbouisson
- Hospital das Clínicas (HC) of the Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil.
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Parra CAM, Carmona MJC, Auler Junior JOC, Malbouisson LMS. Estratégias ventilatórias frente à hipoxemia em cirurgia cardíaca: validação de questionário para anestesiologistas no Brasil. Braz J Anesthesiol 2010. [DOI: 10.1590/s0034-70942010000400008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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