Vasopressin in vasoplegic shock in surgical patients: systematic review and meta-analysis

Purpose: Vasoplegia, or vasoplegic shock, is a syndrome whose main characteristic is reducing blood pressure in the presence of a standard or high cardiac output. For the treatment, vasopressors are recommended, and the most used is norepinephrine. However, new drugs have been evaluated, and conflicting results exist in the literature. Methods: This is a systematic review of the literature with meta-analysis, written according to the recommendations of the PRISMA report. The SCOPUS, PubMed, and ScienceDirect databases were used to select the scientific articles included in the study. Searches were conducted in December 2022 using the terms "vasopressin," "norepinephrine," "vasoplegic shock," "postoperative," and "surgery." Meta-analysis was performed using Review Manager (RevMan) 5.4. The endpoint associated with the study was efficiency in treating vasoplegic shock and reduced risk of death. Results: In total, 2,090 articles were retrieved; after applying the inclusion and exclusion criteria, ten studies were selected to compose the present review. We found no significant difference when assessing the outcome mortality comparing vasopressin versus norepinephrine (odds ratio = 1.60; confidence interval 0.47-5.50), nor when comparing studies on vasopressin versus placebo. When we analyzed the length of hospital stay compared to the use of vasopressin and norepinephrine, we identified a shorter length of hospital stay in cases that used vasopressin; however, the meta-analysis did not demonstrate statistical significance. Conclusions: Considering the outcomes included in our study, it is worth noting that most studies showed that using vasopressin was safe and can be considered in managing postoperative vasoplegic shock.

Trends of vasopressor use in intensive care units in Colombia / Tendencias de consumo de vasopresores en unidades de cuidados intensivos de Colombia

Abstract Introduction Vasopressors are essential in the management of various types of shock. Objective To establish the trend of vasopressors use in the intensive care units (ICU) in a population of patients affiliated with the Colombian Health System, 2010-2017. Methods Observational trial using a population database of patients hospitalized in eleven ICUs in various cities in Colombia. The drugs dispensed to hospitalized patients over 18 years old, from January 2010 until December 2017 were considered. A review and analysis of the vasopressors dispensed per month was conducted, taking into account sociodemographic and pharmacological variables (vasopressor used and daily doses defined per 100/beds/day (DBD). Results 81,348 dispensations of vasopressors, equivalent to 26,414 treatments in 19,186 patients receiving care in 11 hospitals from 7 cities were reviewed. The mean age of patients was 66.3±18.1 years and 52.6 % were males. Of the total number of treatments recorded, 17,658 (66.8 %) were with just one vasopressor. Norepinephrine was the most frequently prescribed drug (75.9 % of the prescriptions dispensed; 60.5 DBD), followed by adrenaline (26.6 %; 41.6 DBD), dopamine (19.4%), dobutamine (16.0 %), vasopressin (8.5 %) and phenylephrine (0.9 %). The use of norepinephrine increased from 2010 to 2017 (+6.19 DBD), whilst the use of other drugs decreased, particularly the use of adrenaline (-60.6 DBD) and dopamine (-10.8 DBD). Conclusions Norepinephrine is the most widely used vasopressor showing a growing trend in terms of its use during the study period, which is supported by evidence in favor of its effectiveness and safety in patients with shock.

Resumen Introducción Los fármacos vasopresores son fundamentales en el manejo de los diferentes tipos de choque. Objetivo Determinar la tendencia de utilización de fármacos vasopresores en unidades de cuidados intensivos (UCI) en una población de pacientes afiliados al Sistema de Salud de Colombia, 2010-2017. Métodos Estudio observacional, a partir de una base de datos poblacional con pacientes hospitalizados en once UCI de diferentes ciudades de Colombia. Se obtuvieron las dispensaciones de pacientes mayores de 18 años hospitalizados desde enero de 2010 hasta diciembre de 2017. Se hizo revisión y análisis de la dispensación mensual de vasopresores. Se consideraron variables sociodemográficas y farmacológicas (medicamento vasopresor usado y dosis diarias definidas por 100 camas/día [DCD]). Resultados Se revisaron 81.348 dispensaciones de vasopresores, equivalentes a 26.414 terapias en 19.186 pacientes atendidos en 11 hospitales de 7 ciudades, cuya edad promedio fue 66,3±18,1 años y el 52,6 % eran hombres. Del total de terapias registradas, 17.658 (66,8 %) fueron con un solo vasopresor. La norepinefrina fue el más comúnmente prescrito (75,9 % de las dispensaciones; 60,5 DCD), seguido por adrenalina (26,6 %; 41,6 DCD), dopamina (19,4 %), dobutamina (16,0 %), vasopresina (8,5 %) y fenilefrina (0,9 %). El uso de norepinefrina se incrementó de 2010 a 2017 (+6,19 DCD), mientras que el de otros fármacos disminuyó, especialmente adrenalina (-60,6 DCD) y dopamina (-10,8 DCD). Conclusiones La norepinefrina es el fármaco vasopresor más utilizado y el que ha demostrado una tendencia de uso incremental durante el periodo de estudio, lo cual está respaldado por evidencia a favor de su efectividad y seguridad en pacientes con choque.

The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial / O efeito de epinefrina, norepinefrina e fenilefrina no tratamento da hipotensão pós-raquianestesia: estudo clínico comparativo

Abstract Background and objectives: Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. Methods: One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 µg.mL−1 (n = 40), epinephrine 5 µg.mL−1 (n = 40), phenylephrine 100 µg.mL−1 (n = 40) or 0.9% saline infusions (n = 40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of intravenous ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. Results: There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p< 0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p= 0.001). Conclusion: There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered an alternative agent for management of spinal hypotension.

Resumo Justificativa e objetivos: Existem dados limitados sobre segurança e eficiência da epinefrina na profilaxia e tratamento da hipotensão arterial associada à raquianestesia. O presente estudo foi realizado para comparar o efeito da epinefrina com norepinefrina e fenilefrina no tratamento da hipotensão após raquianestesia e necessidade de efedrina durante o parto cesáreo. Método: Foram recrutadas 160 parturientes com gestações não complicadas, submetidas a cesariana eletiva sob raquianestesia. Elas foram alocadas aleatoriamente para receber norepinefrina 5 µg.mL-1 (n = 40), epinefrina 5 µg.mL-1 (n = 40), fenilefrina 100 µg.mL-1 (n = 40) ou infusão de solução fisiológica NaCl a 0,9% (n = 40) imediatamente após a indução da raquianestesia. Sempre que houvesse redução da pressão arterial sistólica para valor inferior a 80% da linha de base, 5 mg de efedrina iv eram administrados como vasopressor de resgate. A incidência de hipotensão, o número total de episódios de hipotensão, o número de pacientes que necessitaram de efedrina, o consumo médio de efedrina e os efeitos colaterais foram registrados. Resultados: Não houve diferença estatisticamente significante na incidência de hipotensão materna entre os grupos. O número de pacientes que necessitaram de efedrina foi significantemente maior no grupo solução fisiológica do que no grupo fenilefrina (p< 0,001). No entanto, foi semelhante entre os grupos fenilefrina, norepinefrina e epinefrina. O consumo médio de efedrina foi significantemente maior no grupo solução fisiológica do que nos grupos norepinefrina, epinefrina e fenilefrina (p = 0,001). Conclusão: Não houve diferença estatisticamente significante na incidência de hipotensão e consumo de efedrina durante raquianestesia para parto cesáreo com uso de epinefrina quando comparada à norepinefrina ou fenilefrina. A epinefrina pode ser considerada como agente alternativo para o tratamento da hipotensão após raquianestesia.

Zigomicosis y síndrome hemofagocítico en un paciente inmunocompetente: informe de caso / Zygomycosis and hemophagocytic lymphohistiocytosis in an immunocompetent patient: a case report

Introducción: la zigomicosis es una infección fúngica poco frecuente, con alta tasa de mortalidad y de mal pronóstico. Afecta principalmente a pacientes inmunocomprometidos. La asociación con el síndrome hemofagocítico es extremadamente inusual, más aún en pacientes inmunocompetentes, con pocos ejemplos registrados en la literatura. Caso clínico: se presenta el caso de un paciente masculino inmunocompetente de 40 años con diagnóstico de mucormicosis y síndrome hemofagocítico que evoluciona desfavorablemente, con fallo multiorgánico, a pesar de los esfuerzos médicos. Conclusión: la asociación de mucormicosis con síndrome hemofagocítico en un paciente inmunocompetente es extremadamente rara; existen pocos casos informados en Latinoamérica. Debemos tener presente esta asociación, ya que requiere un tratamiento agresivo y soporte vital avanzado. (AU)

Introduction: zygomycosis is a rare fungal infection that carries with high mortality rates. This poor prognosis, rapidly progressive infection mainly affects immunocompromised patients. The association with hemophagocytic lymphohistiocytosis is extremely unusual, even more in immunocompetent patients, with few cases reported. Case: we present the case of an immunocompetent male patient who was diagnosed with zygomycosis and hemophagocytic lymphohistiocytosis. Despite medical efforts he developed multiorganic failure. Conclusion: the association of mucormycosis with hemophagocytic lymphohistiocytosis in an immunocompetent patient is exceptional with few cases reported in Latin America. We must always suspect this association considering they require aggressive treatment and advanced life support. (AU)

Effects of Beta; 1-adrenoceptors in the Basolateral Amygdala on Spatial Memory, Passive Avoidance, Long-term Potentiation and Neuronal Arborization in the Hippocampal CA1 Region in Response to Unavoidable Stress

Abstract Norepinephrine in the basolateral amygdala (BLA) plays a pivotal role in mediating the effects of stress on memory functions in the hippocampus, however, the functional contribution of β1-adrenergic receptors on the BLA inputs to the CA1 region of hippocampus and memory function are not well understood. In the present study the role of β1-adrenoreceptor in the BLA on memory, neuronal arborization and long-term potentiation (LTP) in the CA1 region of hippocampus was examined by infusion the β1-adrenoreceptor agonist (Dobutamine; 0.5µl/side) or antagonist (Atenolol; 0.25µL/side) bilaterally into the BLA before foot-shock stress. Passive avoidance test results showed that Step-through latency time was significantly decreased in the stress group rats one, four and seven days after the stress, which intra-BLA injection of Atenolol or Dobutamine before stress couldn't attenuate this reduction. Barnes-maze results revealed that infusion of Dobutamine and Atenolol significantly reduced spatial memory indicators such as increased latency time, the number of errors and the distance traveling to achieve the target hole in the stress group. These learning impairments in stress rats correlated with a reduction of LTP in hippocampal CA1 synapses in-vivo, which infusion of Dobutamine and Atenolol couldn't attenuate the population spike amplitude and mean-field excitatory postsynaptic potentials (fEPSP) slope reduction induced by stress. Also, the Golgi-Cox staining demonstrated that infusion of Atenolol attenuated stress decreased CA1 region dendritic and axonal arborization. These results suggest that β1-adrenergic receptors activation or block seem to exacerbate stress-induced hippocampal memory deficits and this effect is independent of CA1 LTP modulation.

Trombo serpiginoso em átrio direito: apresentação atípica de tromboembolismo pulmonar. Relato de caso / Serpiginous thrombus in right atrium: atypical presentation of pulmonary thromboembolism. Case report

O tromboembolismo pulmonar é um grave problema de saúde pública devido ao subdiagnóstico e às elevadas morbidade e mortalidade. Quando a embolia pulmonar é maciça com repercussão hemodinâmica importante e a terapia adequada não ocorre nas primeiras horas, a mortalidade é superior a 85%. Na suspeita clínica de tromboembolismo pulmonar, a avaliação ecocardiográfica pode ter papel fundamental na avaliação da mobilidade e da estrutura do ventrículo direito, presença de hipertensão pulmonar e documentação da presença de trombo. A detecção ecocardiográfica de trombo móvel nas câmaras cardíacas direitas permite identificar um grupo de pacientes de alto risco, com mortalidade muito elevada, quando comparada ao tromboembolismo pulmonar em geral. Além da terapia clínica clássica, com heparinas e trombolíticos, as terapêuticas endovascular e cirúrgica devem ser consideradas e podem contribuir para o prognóstico desses pacientes. Relata-se um caso de uma paciente de 33 anos de idade admitida em uma unidade de emergência da no 8o dia de pós-operatório de apendicectomia, com queixas de dor torácica e dispneia de início súbito. Ecocardiograma transtorácico evidenciou presença de trombo serpiginoso solto em átrio direito, que ocluía intermitentemente a valva tricúspide durante o ciclo cardíaco. Diante das características ecocardiográficas atípicas do trombo e da significativa chance de embolização maciça, optou-se por intervenção cirúrgica de emergência.

Pulmonary thromboembolism is a serious public health problem due to misdiagnosis and high morbidity and mortality. When pulmonary embolism is massive with important hemodynamic repercussion, and the appropriate therapy does not take place in the early hours, mortality is higher than 85%. If there is clinical suspicion of pulmonary thromboembolism, an echocardiographic evaluation may have a key role in the evaluation of mobility and structure of the right ventricle, presence of pulmonary hypertension, and documentation of the presence of thrombus. Echocardiographic detection of mobile thrombus in right cardiac chambers allows the identification of a group of high-risk patients with very high mortality when compared to pulmonary thromboembolism in general . In addition to the classical clinical therapy with heparins and thrombolytics, endovascular and surgical therapy should be considered and may contribute to these patients' prognosis. A case is reported of a 33-year-old female patient admitted to an Emergency Unit at 8th postoperative day (POD) of appendectomy, with complaints of chest pain and dyspnea of sudden onset. Transthoracic echocardiography showed the presence of a floating serpiginous thrombus in the right atrium, which intermittently occluded the tricuspid valve during the cardiac cycle. Due to the atypical echocardiographic features of the thrombus, and significant chance of massive embolization, an emergency surgery was chosen.

Hemodiafiltración intermitente en línea como terapia de reemplazo renal en paciente crítico: Experiencia en un centro de diálisis de agudo / Experience with inline intermittent hemodiafiltration as renal replacement therapy in critically ill patients

Background: In critical patients with acute renal failure, intermittent diffusive renal replacement techniques cause hemodynamic problems due to their high depurative efficiency. This situation is avoided using continuous low efficiency therapies, which are expensive, prevent patient mobilization and add hemorrhagic risk due to systemic anticoagulation. Intermittent and prolonged hemodiafiltration (HDF) has the depurative benefits of diffusion, plus the positive attributes of convection in a less expensive therapy. Aim: To report our experience with intermittent and prolonged on-line HDF in critically ill patients. Patients and Methods: During 2016, HDF therapies performed on critical patients with indication of renal replacement therapy were characterized. The hemodynamic profile was evaluated (doses of noradrenaline, blood pressure, heart rate and perfusion parameters). Results: Fifty-one therapies were performed in 25 critical patients, aged 58 ± 11 years (28% women), with an APACHE II score of 22.1 ±10. The average time of the therapies was 4.15 hours (range 3-8 hours), the replacement volume was 75 ± 18 mL/kg/h and ultrafiltration rate was 226 ± 207 mL/h. The mean initial, maximum and final noradrenaline doses were 0.07 ± 0.1, 0.13 ±0.18 and 0.09 ±0.16 μg/kg/min respectively. No differences between patients with low, medium and high doses of noradrenaline or dose increases during therapy, were observed. The greatest decrease in mean arterial pressure was 15.3% and the maximum increase in heart rate was 12.8%. Anticoagulation was not required in 88% of therapies. Conclusions: High-volume intermittent or prolonged HDF is an effective therapy in critical patients, with good hemodynamic tolerability, lower costs and avoidance of systemic anticoagulation risks.

Eventos adversos durante transporte intra-hospitalar de pacientes críticos em hospital de grande porte / Adverse events during intrahospital transport of critically ill patients in a large hospital

RESUMO Objetivo: Descrever a incidência de eventos clínicos e não clínicos durante o transporte intra-hospitalar de pacientes críticos e analisar os fatores de risco associados. Métodos: Estudo de coorte, com coleta retrospectiva, no período de outubro de 2016 a outubro de 2017, tendo sido analisados todos os transportes intra-hospitalares para fins diagnósticos e terapêuticos em hospital de grande porte, que contava com seis unidades de terapia intensiva adulto, sendo avaliados os eventos adversos e os fatores de risco relacionados. Resultados: No período, foram realizados 1.559 transportes intra-hospitalares, em 1.348 pacientes, com média de idade de 66 ± 17 anos, tempo médio de transporte de 43 ± 34 minutos. Durante o transporte, 19,8% dos pacientes estavam em uso de drogas vasoativas; 13,7% em uso de sedativos e 10,6% estavam sob ventilação mecânica. Eventos clínicos ocorreram em 117 transportes (7,5%) e não clínicos em 125 transportes (8,0%). Falhas de comunicação foram prevalentes, no entanto, aplicando-se análise multivariada, uso de sedativos, noradrenalina e nitroprussiato, e o tempo de transporte maior que 36,5 minutos estiveram associados a eventos adversos clínicos. Uso de dobutamina e tempo de transporte superior a 36,5 minutos estiveram associados a eventos não clínicos. Ao final do transporte, 98,1% dos pacientes apresentaram condições clínicas inalteradas em relação ao seu estado basal. Conclusão: Transportes intra-hospitalares estão relacionados à alta incidência de eventos adversos; o tempo de transporte e a utilização de sedativos e drogas vasoativas estiveram relacionados a esses eventos.

ABSTRACT Objective: To describe the incidence of clinical and non-clinical events during intrahospital transport of critically ill patients and to analyze the associated risk factors. Methods: Cohort study with retrospective data collected from October 2016 to October 2017. All cases of intrahospital transport for diagnostic and therapeutic purposes in a large hospital with six adult intensive care units were analyzed, and the adverse events and related risk factors were evaluated. Results: During the study period, 1,559 intrahospital transports were performed with 1,348 patients, with a mean age of 66 ± 17 years and a mean transport time of 43 ± 34 minutes. During transport, 19.8% of the patients were using vasoactive drugs; 13.7% were under sedation; and 10.6% were under mechanical ventilation. Clinical events occurred in 117 transports (7.5%), and non-clinical events occurred in 125 (8.0%) transports. Communication failures were prevalent; however, the multivariate analysis showed that the use of sedatives, noradrenaline and nitroprusside and a transport time greater than 36.5 minutes were associated with adverse clinical events. The use of dobutamine and a transport time greater than 36.5 minutes were associated with non-clinical events. At the end of transport, 98.1% of the patients presented unchanged clinical conditions compared with baseline. Conclusion: Intrahospital transport is related to a high incidence of adverse events, and transport time and the use of sedatives and vasoactive drugs were related to these events.

Factors associated to potential drug interactions in one Intensive Care Unit: a cross-sectional study / Factores asociados a interacciones medicamentosas potenciales en un Centro de Terapia Intensiva: estudio transversal / Fatores associados a interações medicamentosas potenciais em um Centro de Terapia Intensiva: estudo transversal

ABSTRACT Objective: to identify the factors associated to Potential Drug Interactions with High Alert Medications in the Intensive Care Unit of a Sentinel Hospital. Methods: a cross-sectional, retrospective study using a quantitative approach carried out at a Sentinel Hospital in Rio de Janeiro. The research was based on the analysis of the prescriptions of patients hospitalized in the Intensive Care Unit of the Hospital, in a period of one year, in order to identify the drug interactions related to high alert medications in these prescriptions. Results: Of the 60 prescriptions analyzed, 244 were selected. In these prescriptions, 846 potential drug interactions related to high alert medications and 33 high alert medications were identified. Of the 112 types of potential drug interactions identified, some were more recurrent: tramadol e ondansetron, midazolam and omeprazole, regular insulin and hydrocortisone, fentanyl and midazolam, and regular insulin and noradrenaline. The variables polypharmacy, length of hospital stay, and some specific medications were associated with drug interactions with high alert medications. Conclusion and Implications for practice: It is important to strengthen strategies to reduce adverse drug events. Therefore, the relevance of studies that investigate the origin of these events is highlighted. Drug interactions can represent medication errors. It's indispensable to work with strategies to better manage the medication system.

RESUMEN Objetivo: identificar los puntos asociados a las Interacciones Medicamentos Potenciales con Medicamentos de alta vigilancia en un Centro de Cuidados Intensivos de un Hospital de Guardia. Métodos: estudio transversal, retrospectivo, de abordaje cuantitativo, realizado en un hospital de guardia en Rio de Janeiro. Esta investigación se basó en el análisis de las prescripciones medicamentosas de pacientes internados en un Centro de Cuidados Intensivos de un hospital, en un período de 1 año, con el objetivo de identificar las interacciones medicamentosas relacionadas con Medicamentos de alta Vigilancia recurrentes en las mismas. Resultados: de los informes analizados, se seleccionaron 244 prescripciones medicamentosas. En las 244 prescripciones de medicamentos, se pudieron identificar 846 Interacciones de Medicamentos Potenciales (IMP) relacionados a Medicamentos de Alta Vigilancia y 33 Medicamentos de Alta Vigilancia. De los 112 tipos de interacciones de medicamentos potenciales identificados, algunos han sido más recurrentes; a saber: tramadol y ondansetrón, midazolam y omeprazol, insulina regular e hidrocortisona, fentanilo y midazolam, insulina regular y noradrenalina. Las variables polifarmacia, tiempo de internación y algunos medicamentos específicos se asociaron a las interacciones medicamentosas potenciales con Medicamentos de Alta Vigilancia. Conclusión e Implicaciones para la práctica: es importante fortalecer las estrategias para reducir los eventos adversos relacionados con medicamentos. Por lo tanto, se destaca la relevancia de los estudios que plantean la naturaleza de estos eventos. Las interacciones medicamentosas pueden provocar errores de medicación. Es imprescindible trabajar con estrategias para administrar mejor el sistema de medicación.

RESUMO Objetivo: Identificar os fatores associados às Interações Medicamentosas Potenciais com Medicamentos de alta vigilância em Centro de Terapia Intensiva de um Hospital Sentinela. Métodos: Estudo transversal, retrospectivo, de abordagem quantitativa, realizado em um hospital sentinela no Rio de Janeiro. A pesquisa apoiou-se na análise das prescrições de pacientes internados no setor, com recorte temporal de 1 ano, a fim de identificar as interações medicamentosas relacionadas a medicamentos de alta vigilância recorrentes nas mesmas. Resultados: Dos 60 prontuários analisados, selecionaram-se 244 prescrições. Nelas identificaram-se 846 interações medicamentosas potenciais, relacionadas aos medicamentos de alta vigilância e 33 medicamentos de alta vigilância. Dos 112 pares de interações identificadas, foram mais recorrentes: tramadol e ondansetrona, midazolam e omeprazol, insulina regular e hidrocortisona, fentanil e midazolam, e insulina regular e noradrenalina. As variáveis polifarmácia, tempo de internação e alguns medicamentos específicos foram associadas às interações com medicamentos de alta vigilância. Conclusão e Implicações para a prática: É importante fortalecer as estratégias para reduzir os eventos adversos relacionados a medicamentos. Portanto, destaca-se a relevância de estudos que levantem a natureza desses eventos. As interações medicamentosas podem configurar erros de medicação. Portanto, é indispensável que se trabalhe com estratégias para melhor manejar o sistema de medicação.

Utilização da vasopressina no tratamento de choque séptico refratário / Use of vasopressin in the treatment of refractory septic shock

RESUMO Objetivo: Avaliar a evolução em curto prazo de pacientes com choque séptico refratário à norepinefrina tratados com vasopressina em uma unidade de terapia intensiva de um hospital universitário. Métodos: Foi realizado estudo retrospectivo não comparado (série de casos). Foram coletados dados clínicos, laboratoriais e antropométricos de pacientes que receberam infusão de vasopressina para tratamento de choque refratário a catecolaminas no período de dezembro de 2014 a junho de 2016. Para a avaliação de gravidade, foram utilizados o APACHE II e o SOFA. O desfecho principal foi mortalidade em 3 e em 30 dias. Resultados: Foram incluídos 80 pacientes, sendo 60% do sexo masculino. Em 86,3% dos casos, verificou-se APACHE II nas faixas mais altas (> 20). A mortalidade em 30 dias foi de 86,2%, sendo que 75% dos pacientes foram a óbito dentro de 72 horas após início do uso da vasopressina. Conclusão: A série avaliada apresentou alta mortalidade nas primeiras 72 horas de tratamento com vasopressina. O uso de vasopressina em pacientes refratários à norepinefrina teve pouco ou nenhum impacto na mortalidade. Não é possível excluir que a alta mortalidade no presente estudo esteja vinculada ao início relativamente tardio (após estabelecida refratariedade à norepinefrina) da vasopressina, devendo essa hipótese ser melhor avaliada por estudo randomizado.

ABSTRACT Objective: To evaluate the short-term evolution of patients with septic shock refractory to norepinephrine treated with vasopressin in an intensive care unit of a university hospital. Methods: An unmatched retrospective study (case series) was performed. Clinical, laboratory, and anthropometric data were collected from patients who received vasopressin infusion for treatment of catecholamine-refractory shock from December 2014 to June 2016. For the assessment of severity, APACHE II and SOFA scores were used. The main outcome was mortality at 3 and 30 days. Results: A total of 80 patients were included, of which 60% were male. In 86.3% of the cases, APACHE II was observed in the highest ranges (> 20). The 30-day mortality was 86.2%, and 75% of the patients died within 72 hours after starting vasopressin. Conclusion: The series evaluated had high mortality in the first 72 hours of treatment with vasopressin. The use of vasopressin in patients who are refractory to norepinephrine had little or no impact on mortality. It was not possible to exclude the possibility that the high mortality in the present study was linked to the relatively late onset (after established refractoriness of norepinephrine) of vasopressin; this hypothesis should be further evaluated in a randomized study.

Cuidados pós-ressuscitação-cardiopulmonar (RCP) / Post-cardiopulmonary resuscitation (CPR) care

Evitar novos episódios de parada cardiorrespiratória (PCR). Identificar e tratar as causas que levaram o paciente à PCR. Oferecer suportes ventilatório, hemodinâmico, neurológico e metabólico. Realizar a modulação terapêutica de temperatura para todos os pacientes que retornaram à circulação espontânea. Indicação de cateterismo cardíaco para pacientes sem causa estabelecida de PCR quando a causa pode ser um evento coronariano

Avoid further episodes of cardiopulmonary arrest (CPA). Identify and treat the causes of the patient's CPA. Provide ventilatory, hemodynamic, neurological and metabolic support. Perform therapeutic temperature modulation for all patients who have resumed spontaneous circulation. Indication of cardiac catheterization for patients with no established cause of CPA when the cause may be a coronary event

Evaluación de síndrome metabólico en varones hospitalizados en Unidad de Corta Estadía Psiquiátrica Marzo 2017 / Evaluation of metabolic syndrome in Hospitalized Men in the Short Stay Psychiatric Unit. March 2017

El síndrome metabólico (SM) corresponde a un conjunto de factores de riesgo derivados de la obesidad visceral e insulinoresistencia. 35.3% de la población adulta chilena presentó SM en el período 2009 - 2010, con diferencia significativa entre hombres y mujeres (41.6% vs 30.9%, respectivamente). En Estados Unidos se ha calculado que la media de años potencialmente perdidos en pacientes con enfermedades mentales va de 25 a 30, comparada con la población general. La principal causa de muerte es la enfermedad coronaria. La mayoría de los pacientes en tratamiento neuroléptico en hospitales psiquiátricos no reciben control de factores de riesgo metabólicos. La evidencia señala que los pacientes esquizofrénicos no son adecuadamente pesquisados ni tratados por Dislipidemia (hasta un 88% de estos pacientes siguen sin tratamiento) ni por hipertensión (hasta un 62%). El objetivo de este trabajo es evaluar factores de riesgo cardiovascular en varones hospitalizados en unidad de corta estadía psiquiátrica del Instituto Psiquiátrico Dr. José Horwitz Barak. Se evaluó a 35 pacientes varones, de los cuales un 37% presentó SM, un 45.3% presentó sobrepeso.

The metabolic syndrome (MS) corresponds to a set of risk factors derived from visceral obesity and insulin resistance. 35.3% of the Chilean adult population had MS in the 2009-2010 period, with a significant difference between men and women (41.6% vs 30.9%, respectively). In the United States, it has been estimated that the average number of years potentially lost in patients with mental illness ranges from 25 to 30, compared with the general population. The main cause of death is coronary heart disease. Most patients on neuroleptic treatment in psychiatric hospitals do not receive control of metabolic risk factors. The evidence indicates that schizophrenic patients are not adequately researched or treated for dyslipidemia (up to 88% of these patients remain untreated) or hypertension (up to 62%). OBJECTIVE: To evaluate cardiovascular risk factors in hospitalized men in a short stay psychiatric unit of the Psychiatric Institute Dr. José Horwitz Barak. Thirty-five male patients were evaluated, of which 37% had MS, and 45.3% were overweight.

Valor pronóstico de los niveles de propéptido N-terminal del procolágeno tipos I y III asociados al remodelamiento ventricular en pacientes con insuficiencia cardiaca crónica / Prognostic value of procollagen types I and III N-terminal propeptide as regards ventricular remodelling in patients with chronic heart failure

Resumen Introducción: La insuficiencia cardiaca constituye el estadio final de muchas cardiopatias. Aunque los cambios en la composición de la matriz extracelular relacionados con el proceso de remodelamiento ventricular han sido descritos, ni la evolución ni el impacto clínico de la fibrogénesis miocárdica en pacientes con IC están completamente entendidos. Objetivo: Determinar si los precursores de la síntesis y degradación del colágeno son útiles en la predicción de hospitalización, muerte o necesidad de trasplante cardiaco en pacientes con insuficiencia cardiaca crónica. Métodos: Se estudiaron 204 pacientes con insuficiencia cardiaca crónica entre 2015 y 2016; 106 con miocardiopatía isquémica y 98 con miocardiopatía dilatada. Se midieron los niveles séricos de noradrenalina, fracción N-terminal del propéptido natriurético cerebral, propéptido N-terminal del procolágeno tipo I (PINP) y propéptido N-terminal del procolágeno tipo III (PIIINP). Se determinaron volúmenes y fracción de eyección del ventrículo izquierdo, clase funcional y tratamiento médico. Resultados: Durante el seguimiento hubo 55 hospitalizaciones, 7 muertes y 9 trasplantes. La edad (p < 0,001), los niveles de PINP (p = 0,04), PIIINP (p = 0,016) y volúmenes del ventrículo izquierdo (p < 0,05), fueron significativamente mayores en los pacientes que alcanzaron el desenlace primario. En pacientes con dilatación severa del ventrículo izquierdo (IVTDVI > 110ml/m2, IVTSVI > 50ml/m2), niveles de PIIINP > 6,2 (g/L y PINP > 40 (g/L se asociaron con mayor riesgo de hospitalización, muerte o necesidad de trasplante (sobrevida libre de eventos a 12 meses: 45% versus 95%, p < 0,0001). Conclusiones: Los niveles circulantes de PINP y PIIINP, se correlacionan con el remodelamiento del ventrículo izquierdo y predicen desenlaces en pacientes con insuficiencia cardiaca crónica.

Abstract Introduction: Heart failure (HF) is the end-stage of many heart diseases. Although the changes in the composition of the extracellular matrix associated with the ventricular remodelling process have been described, neither the evolution nor the clinical impact of the myocardial fibrogenesis in patients with HF are completely understood. Objective: To determine if the precursors of the synthesis and degradation of collagen are useful in the prediction of hospital admissions, death, or the need for a heart transplant in patients with chronic heart failure (CHF). Methods: A total of 204 patients with chronic heart failure were studied between the years 2015 and 2016, of whom 106 had ischaemic heart disease, and 98 had dilated cardiomyopathy. Measurements were made of the serum levels of noradrenaline, N-terminal pro-B-type natriuretic peptide, procollagen type I N-terminal propeptide, and procollagen type III N-terminal propeptide (PIIINP). The left ventricular volumes and ejection fraction were determined, as well a record made of the functional class and medical treatment. Results: During follow-up, there were 55 hospital admissions, 7 deaths and 9 transplants. Age (p<0,001), PINP levels (p=0,04), PIIINP levels (p=0,016), and left ventricular volumes (p<0,05), were significantly higher in patients who achieved the primary outcome. In patients with severe dilation of the left ventricle (LV diastolic volume index, LVDVI > 110 ml/m2, LV systolic volume index, LVTSVI > 50 ml/m2), PIIINP levels > 6.2 (g/L and a PINP > 40 (g/L, were associated with a higher risk of hospital admission, death, or need of a transplant (event-free survival at 12 months: 45% versus 95%, p<0,0001). Conclusions: The circulating levels of PINP and PIIINP are associated with left ventricular remodelling, and predict the outcomes in patients with chronic heart failure.

Involvement of catecholamines in the myocardium of rats submitted to experimental model of portal hypertension / Envolvimento das catecolaminas no miocárdio de ratos submetidos a modelo experimental de hipertensão portal

ABSTRACT Background: The role of autonomic nervous system in the development and maintenance of portal hypertension is not fully elucidated. It is known that the gene expression of norepinephrine in the superior mesenteric artery varies with time, and it may contribute for splanchnic vasodilation and its consequent hemodynamic repercussions. It is still not known exactly how the adrenergic expression behaves at the heart level in the initial stages of this process. Aim: To evaluate the immunohistochemical expression of the enzyme tyrosine hydroxylase (tyrosine 3-monooxygenase), involved in the synthesis of norepinephrine, in the myocardium of rats submitted to partial ligation of the portal vein. Methods: Twenty-four Wistar rats were divided into two groups: Sham Operated and Portal Hypertension. The partial ligation was performed in the Portal Hypertension group, and after 1/6/24 h and 3/5/14 days the animals were euthanized. Immunohistochemical analysis was performed to quantify the expression of the stained enzyme using the ImageJ program. Results: The Portal Hypertension group expressed percentages between 4.6-6% of the marked area, while the Sham Operated group varied between 4-5%. Although there was no statistical significance, the percentage stained in the Portal Hypertension group followed an increasing pattern in the first 6 h and a decreasing pattern after 24 h, which was not observed in the Sham Operated group. Conclusion: The expression of noradrenaline in rat myocardium during the first two weeks after partial ligation of the portal vein, with tyrosine hydroxylase as marker, did not show differences between groups over time.

RESUMO Racional: O papel do sistema nervoso autônomo na hipertensão portal não está completamente elucidado. Sabe-se que, nessa condição, a expressão gênica da norepinefrina na artéria mesentérica superior modifica-se com o tempo, podendo ser importante contribuinte para a vasodilatação esplâncnica e suas repercussões hemodinâmicas. Apesar dos estudos sobre as repercussões cardiovasculares na hipertensão portal, ainda não se sabe como a expressão adrenérgica se comporta a nível cardíaco nas etapas iniciais desse processo. Objetivo: Avaliar a expressão imunoistoquímica da enzima tirosina hidroxilase (tirosina 3-mono-oxigenase), relacionada à síntese da norepinefrina, no miocárdio de ratos submetidos à ligadura parcial da veia porta. Métodos: Foram utilizados 24 ratos, distribuídos em dois grupos: Sham Operated e Hipertensão Portal. A ligadura parcial da veia porta foi realizada apenas no grupo Hipertensão Portal e, após 1/6/24 h e 3/5/14 dias, os animais foram eutanasiados. Foi feita a análise imunoistoquímica para quantificar a expressão da enzima corada, utilizando o programa ImageJ. Resultados: No grupo Hipertensão Portal, o miocárdio expressou percentuais entre 4,6-6% de área marcada, enquanto que no grupo Sham Operated variou entre 4-5%, sem significância estatística. Apenas no grupo Hipertensão Portal, a porcentagem corada pela enzima seguiu padrão crescente nas primeiras 6 h e decrescente após 24 h. Conclusão: A expressão da noradrenalina no miocárdio de ratos durante as primeiras duas semanas após a ligadura parcial da veia porta, tendo como marcador a enzima tirosina hidroxilase, não apresentou diferenças entre grupos ao longo do tempo.

Opções de tratamento cirúrgico em lesões cutâneas por extravasamento acidental de drogas: experiência do Hospital das Clínicas da Faculdade de Medicina da USP / Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo

RESUMO Objetivo: relatar a experiência da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no tratamento de lesões cutâneas por extravasamento acidental de drogas. Métodos: foram incluídos os pacientes com lesões por extravasamento de drogas num período de 18 meses. Os seguintes parâmetros foram avaliados retrospectivamente: idade, diagnósticos durante internação e comorbidades, níveis séricos de albumina e hemoglobina, local de internação, droga envolvida, segmento anatômico acometido, conduta terapêutica e óbito durante internação. Resultados: foram acompanhados 14 pacientes. A principal droga envolvida foi a noradrenalina (21%). Todos os pacientes foram submetidos a desbridamento da necrose tecidual. Três pacientes foram submetidos a retalhos após preparo do leito com terapia por pressão negativa, com bons resultados. Sete pacientes não tiveram tratamento definitivo de suas lesões por falta de condições clínicas. Conclusão: o tratamento definitivo por meio de retalhos se mostrou adequado para os casos de feridas por extravasamento de drogas em tecido subcutâneo, quando há exposição de estruturas nobres, em pacientes com condições clínicas favoráveis.

ABSTRACT Objective: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs. Methods: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization. Results: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions. Conclusion: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline

OBJECTIVES: To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS: This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS: Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS: In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min.

Uso oportuno de vasoprotectores en choque séptico / Timely use of vasoprotectors in septic shock

El estado de choque septico es una afección grave que ocurre en presencia de una posible infección con posterior fallo multiorgánico, corresponde a una de las primeras causas por las que pacientes son ingresados a la unidad de cuidado intensivo y ocurre con mayor frecuencia en pacientes de edad avanzada por ello es de vital importancia la temprana identificación, manejo guiado mediante metas y la acertada resolución, para ello se establece el oportuno uso de vasopresores como parte de la terapia...AU)

The state of septic shock is a serious condition that occurs in the presence of a possible infection with subsequent multi-organ failure, corresponds to one of the first causes for which patients are admitted to the intensive care unit and occurs more frequently in elderly patients. advanced, therefore, it is vitally important the early identification, guided management through goals and the correct resolution, for this the opportune use of vasopressors is established as part of the therapy ... AU)

Perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on multiple antihypertensive medications / Choque anafilático refratário perianestésico com cefuroxima em paciente com história de alergia à penicilina recebendo vários medicamentos anti-hipertensivos

Abstract We report a case of perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on regular therapy with atenolol, losartan, prazosin and nicardipine. Severe anaphylactic shock was only transiently responsive to 10 mL of (1:10,000) epinephrine and needed norepinephrine and dopamine infusion. Supportive therapy with vasopressors and inotropes along with mechanical ventilation for the next 24 hours resulted in complete recovery. She was successfully operated upon 2 weeks later with the same anesthetic drugs but intravenous ciprofloxacin as the alternative antibiotic for perioperative prophylaxis.

Resumo Relatamos um caso de choque anafilático refratário no período perianestésico com cefuroxima em paciente com história de alergia à penicilina em terapia regular com atenolol, losartan, prazosina e nicardipine. O choque anafilático grave foi apenas transitoriamente responsivo a 10 mL de epinefrina (1:10000) e precisou de infusão de norepinefrina e dopamina. A terapia de apoio com vasopressores e inotrópicos, juntamente com ventilação mecânica por 24 horas, resultou em recuperação completa. A paciente foi operada com sucesso duas semanas mais tarde, com os mesmos agentes anestésicos, mas com ciprofloxacina intravenosa como antibiótico opcional para a profilaxia perioperatória.

Quality of Life Score as a Predictor of Death in Dogs with Degenerative Mitral Valve Disease / Escore de Qualidade de Vida como Preditor de Mortalidade em Cães com Doença Degenerativa da Valva Mitral

Abstract Background: The knowledge of the variables predicting mortality is important in clinical practice and for therapeutic monitoring in mitral valve disease. Objectives: To determine whether a quality of life score evaluated with the Functional Evaluation of Cardiac Health questionnaire would predict mortality in dogs with degenerative mitral valve disease (DMVD). Methods: Thirty-six client-owned dogs with mitral valve disease underwent clinical, laboratory, and echocardiographic evaluations at baseline and were monitored for 6 months. Cardiovascular death was the primary outcome. Results: The 36 dogs were classified as survivors or nonsurvivors. Higher values of the following variables were obtained at baseline in the nonsurviving group (12 dogs): amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, plasma norepinephrine, heart rate, quality of life score, diastolic left ventricular internal dimension to aortic root ratio, systolic left ventricular internal dimension to aortic root ratio, and left atrium to aortic root ratio. NT-proBNP levels and quality life score were independently associated with death in the multivariable analysis. Conclusion: The quality life score was an independent variable for cardiac death in dogs with DMVD. This result is encouraging, as this score is easy to apply and does not require any technology, only a veterinarian and an observant owner.

Resumo Fundamento: O conhecimento das variáveis preditoras de mortalidade é importante para a prática clínica e para o acompanhamento terapêutico na doença da valva mitral. Objetivos: Determinar se um escore de qualidade de vida avaliado com o Functional Evaluation of Cardiac Health poderia auxiliar na predição de mortalidade em cães com doença degenerativa da valva mitral (DDVM). Métodos: Trinta e seis cães de estimação com doença valvar mitral foram submetidos a avaliação clínica, laboratorial e ecocardiográfica no início do estudo e monitorizados durante 6 meses. A morte cardiovascular foi o desfecho primário. Resultados: Os 36 cães foram classificados como sobreviventes ou não sobreviventes. Os valores mais elevados das seguintes variáveis foram obtidos no início do estudo no grupo de não sobreviventes (12 cães): fragmento N-terminal do peptídeo natriurético tipo B (NT-proBNP), norepinefrina plasmática, frequência cardíaca, escore de qualidade de vida, razão da dimensão interna diastólica do ventrículo esquerdo e raiz aórtica, razão da dimensão interna sistólica do ventrículo esquerdo e raiz aórtica e a relação da dimensão do átrio esquerdo e a raiz aórtica. Concentrações de NT-proBNP e o escore de qualidade de vida foram independentemente associados com morte na análise multivariada. Conclusão: O escore de qualidade de vida foi uma variável independente para a morte por doença cardíaca em cães com DDVM. Este resultado é encorajador, pois este escore é de fácil aplicação e não requer o emprego de tecnologia, necessitando apenas de um veterinário e um dono observador.