Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial.

Importance: Perioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial. Objective: To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT. Design, Setting, and Participants: Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014). Interventions: Intensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT. Main Outcomes and Measures: Severity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality. Results: All 320 patients (median age, 62 years; IQR, 56-69 years; 125 women [39%]) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI, 1.7 to 2.0) and a median 1.7 (IQR, 1.0-2.0) pulmonary complications score vs 2.1 (95% CI, 2.0-2.3) and 2.0 (IQR, 1.5-3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI, 1.22 to 2.83; P = .003). The mean hospital stay for the moderate group was 12.4 days vs 10.9 days in the intensive group (absolute difference, -1.5 days; 95% CI, -3.1 to -0.3; P = .04). The mean ICU stay for the moderate group was 4.8 days vs 3.8 days for the intensive group (absolute difference, -1.0 days; 95% CI, -1.6 to -0.2; P = .01). Hospital mortality (2.5% in the intensive group vs 4.9% in the moderate group; absolute difference, -2.4%, 95% CI, -7.1% to 2.2%) and barotrauma incidence (0% in the intensive group vs 0.6% in the moderate group; absolute difference, -0.6%; 95% CI, -1.8% to 0.6%; P = .51) did not differ significantly between groups. Conclusions and Relevance: Among patients with hypoxemia after cardiac surgery, the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital. Trial Registration: clinicaltrials.gov Identifier: NCT01502332.

Physiological abnormalities and adverse events during physical therapy in the intensive care unit after cardiac surgery: A prospective observational study.

BACKGROUND: After cardiac surgery, physiological abnormalities or adverse events might occur in patients in the intensive care unit (ICU) during physical therapy care. Identifying these events may help improve patient safety and care. OBJECTIVES: To estimate the incidence and the degree of severity of physiological abnormalities or adverse events during physical therapy interventions provided in the ICU after cardiac surgery. To explore the relationship between these events and patients' characteristics and clinical outcomes. METHODS: Prospective observational study of adult patients in the postoperative period of cardiac surgery admitted to the ICU of a referenced university hospital. Physical therapy interventions were observed by a team trained to evaluate and register the occurrence of physiological abnormalities or adverse events and grading their consequences. We compared baseline characteristics and outcomes of patients with versus without these events. RESULTS: We observed 935 physical therapy interventions in 323 patients, of which 189 (20%, 95% confidence interval: 18, 23%) resulted in physiological abnormalities or adverse events. The highest incidences of these events were observed during endotracheal suctioning (44%), walking (40%), and noninvasive ventilation (37%). Hemodynamic changes were the most frequent events accounting for 74% of all events. Only 2% of interventions resulted in mild harm and 0.2% in moderate harm. The presence of comorbidities was associated (p = 0.03) with the occurrence of these events. CONCLUSION: Physiological abnormalities or adverse events occurred in 20% of physical therapy interventions in patients in the ICU after cardiac surgery, with 10% of those resulting in negative effects. Only the presence of comorbidities was associated with the occurrence of these events.

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery.

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period.

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period.

Risco de quedas em idosos residentes numa comunidade rural / Risk of falls in elderly people living in a rural community

Enquadramento: A população idosa encontra-se exposta a um risco acrescido de quedas. Com o envelhecimento demográfico estima-se um aumento de quedas e suas consequências. O conhecimento do risco e dos fatores de risco para as quedas, permitem uma intervenção multifatorial dirigida, contribuindo para um envelhecimento ativo e saudável. Objetivo: Avaliar o risco de quedas em idosos residentes numa comunidade rural. Métodos: Estudo quantitativo, transversal, descritivo e correlacional, realizado numa amostra probabilística, selecionada de forma aleatória simples, com uma frequência estimada de 50% e com margem de erro aceitável de 5% e um nível de confiança de 95%. Constituída por 321 idosos, inscritos numa Unidade de Cuidados de Saúde Personalizados, dos quais 175 (54,5%) são do sexo feminino e 146 (45,5%) do sexo masculino. A colheita de dados foi efetuada através do hétero preenchimento de um protocolo de avaliação, utilizando-se o Índice Modificado de Barthel, versão portuguesa Araújo, Ribeiro, Oliveira e Pinto (2007) e a escala de Morse, validada para a população portuguesa por Costa-Dias, Ferreira e Oliveira (2014). Resultados: A prevalência de quedas nos últimos 12 meses foi de 45,5%. Quanto ao tipo de queda verificamos que os idosos relataram na sua maioria o tropeçar (54,1%), escorregar (32,2%) e perder o equilíbrio (26,7%). Verificamos que 31,5% dos idosos não sofreram lesões, dos que apresentaram lesões as mais relatadas foram as escoriações (32,9%), fraturas (16,4%) e contusões (15,8%). A escala de Morse permitiu-nos verificar que 33% da amostra apresenta baixo risco de quedas e 7,2% alto risco. O risco de quedas associou-se com a idade, o número de medicamentos tomados diariamente, o índice de Barthel, o sexo, o estado civil, as pessoas com quem o idoso vive atualmente, o rendimento mensal, as habilitações literárias, o tipo de apoio, a prática de atividade física nos últimos 30 dias, a presença de dor, as quedas nos últimos 12 meses e o uso de auxiliares de marcha. Conclusões: Os resultados sugerem a necessidade de implementação de um projeto comunitário no âmbito da prevenção das quedas. Este projeto deve abranger prioritariamente os idosos com alto risco de quedas e as intervenções devem ser direcionadas para os fatores de risco identificados e potencialmente modificáveis.

Background: The elderly population is exposed to a greater risk of falls. Due to the demographic ageing, it is estimated an increase in the number of falls and the consequences associated with it. Understanding the risk and the fall risk factors allows to have a specific multifactorial intervention, leading, therefore, to an active and healthy ageing. Objective: To evaluate the risk of falls in elderly people living in a rural community. Methods: Quantitative, cross-sectional, descriptive and correlational study conducted in a probability sample, randomly selected, with a 50% estimated frequency and a 5% acceptable margin of error and a 95% confidence level. The sample consists of 321 elderly people enrolled in a Personalized Health Care Unit. 175 (54,5%) are female and 146 (45,5%) are male. The data were collected through interview, filling in an assessment protocol form, using the Modified Barthel Index, Portuguese version Araújo, Ribeiro, Oliveira and Pinto (2007), and the Morse Scale, validated for the Portuguese population by Costa -Dias, Ferreira and Oliveira (2014). Results: The prevalence of falls in the last 12 months was 45,5%. As far as the type of fall is concerned, the elderly reported mostly tripping (54,1%), slipping (32,2%) and losing balance (26,7%). We found that 31,5% of the elderly had no injuries. The elderly who had injuries reported the following ones: abrasions (32,9%), fractures (16,4%) and bruises (15,8%). The Morse Scale allowed us to verify that 33% of the sample presents a low risk of falls and 7,2%. a high risk of falls. The risk of falls was associated with age, number of medication taken daily, Barthel's Index, gender, marital status, people with whom the elderly currently live, monthly income, education, type of support, practice of physical activity within the last 30 days, presence of pain, falls within the last 12 months and the use of walking aids. Conclusion: The results indicate the need to implement a community project to prevent falls. This project should focus primarily on the elderly population with a higher risk of falls and the interventions should focus on the identified and potentially modifiable risk factors.

Application of noninvasive ventilation in acute respiratory failure after cardiovascular surgery.

OBJECTIVE: To examine ventilatory response, oxygenation-related, and hemodynamics of patients with hypoxemic acute respiratory failure (ARF) submitted to noninvasive mechanical ventilation (NIV) during the postoperative phase of cardiovascular surgery in order to identify predictive variables of success, and to compare the different types of NIV. METHODS: Seventy patients with hypoxemic ARF were randomized to one of three modalities of NIV--continuous positive airway pressure (CPAP) and ventilation with two pressure levels (PEEP + SP and BiPAP). Ventilation, oxygenation-related, and hemodynamics variables were analyzed at pre-application, and 3, 6, and 12 hours after the protocol began. RESULTS: Thirteen patients were excluded. Thirty-one patients progressed to independence from ventilatory support and comprised the success group, and 26 required orotracheal intubation and were considered the nonsuccess group. Age, initial heart rate (HR), and respiratory rate (RR) showed elevated levels in the nonsuccess group (p=0.042, 0.029, and 0.002, respectively). A greater number of intraoperative complications were seen in the nonsuccess group (p=0.025). Oxygenation variables increased only in the success group. Among the NIV types, 57.9% of patients in the ventilator group, 57.9% in the two-pressure levels group, and 47.3% in the CPAP group progressed with success. Oxygenation and RR variables showed improvement only in the groups with two pressure levels. CONCLUSION: Patients with hypoxemic ARF in the postoperative stage after cardiovascular surgery showed better oxygenation, RR, and HR during NIV application. In older patients and those with higher baseline RR and HR values, NIV was not sufficient to reverse ARF. The two-pressure level modes showed better results.

Aplicação da ventilação não-invasiva em insuficiência respiratória aguda após cirurgia cardiovascular / Application of noninvasive ventilation in acute respiratory failure after cardiovascular surgery

OBJETIVOS: Verificar as respostas ventilatória, de oxigenação e hemodinâmica de pacientes com insuficiência respiratória aguda (IResp) hipoxêmica submetidos a aplicação de ventilação mecânica não-invasiva (VMNI) no pós-operatório de cirurgia cardiovascular, buscando variáveis preditoras de sucesso, e comparar as diferentes modalidades de VMNI. MÉTODOS: No total, 70 pacientes com IResp hipoxêmica foram randomizados em uma das três modalidades de VMNI: pressão positiva contínua em vias aéreas (CPAP) e ventilação com dois níveis pressóricos (PEEP + PS e BiPAP®). Foram analisadas variáveis ventilatórias, de oxigenação e hemodinâmicas nos períodos pré-aplicação, 3, 6 e 12 horas após iniciado o protocolo. RESULTADOS: Foram excluídos 13 pacientes. Dos pacientes restantes, 31 evoluíram para independência do suporte ventilatório, constituindo o grupo sucesso, e 26 necessitaram de intubação orotraqueal, sendo considerados insucesso. Idade e níveis iniciais de freqüência cardíaca (FC) e de freqüência respiratória (FR) apresentaram valores elevados no grupo insucesso (p = 0,042, 0,029 e 0,002, respectivamente). O grupo insucesso apresentou maior número de intercorrências intra-operatórias (p = 0,025). As variáveis de oxigenação elevaram-se somente no grupo sucesso. Dentre as modalidades de VMNI, evoluíram como sucesso 57,9 por cento dos pacientes no grupo ventilador, 57,9 por cento no bi-nível e 47,3 por cento no CPAP. Variáveis de oxigenação e FR apresentaram melhora somente nos grupos com dois níveis pressóricos. CONCLUSÃO: Pacientes com IResp hipoxêmica no pós-operatório de cirurgia cardiovascular apresentaram melhora da oxigenação, da FR e da FC durante a aplicação de VMNI. Em pacientes mais idosos e com valores iniciais de FR e de FC mais elevados, a VMNI não foi suficiente para reverter o quadro de IResp. Modalidades com dois níveis pressóricos apresentaram resultados superiores.

OBJECTIVE: To examine ventilatory response, oxygenation-related, and hemodynamics of patients with hypoxemic acute respiratory failure (ARF) submitted to noninvasive mechanical ventilation (NIV) during the postoperative phase of cardiovascular surgery in order to identify predictive variables of success, and to compare the different types of NIV. METHODS: Seventy patients with hypoxemic ARF were randomized to one of three modalities of NIV - continuous positive airway pressure (CPAP) and ventilation with two pressure levels (PEEP + SP and BiPAP®). Ventilation, oxygenation-related, and hemodynamics variables were analyzed at pre-application, and 3, 6, and 12 hours after the protocol began. RESULTS: Thirteen patients were excluded. Thirty-one patients progressed to independence from ventilatory support and comprised the success group, and 26 required orotracheal intubation and were considered the nonsuccess group. Age, initial heart rate (HR), and respiratory rate (RR) showed elevated levels in the nonsuccess group (p=0.042, 0.029, and 0.002, respectively). A greater number of intraoperative complications were seen in the nonsuccess group (p=0.025). Oxygenation variables increased only in the success group. Among the NIV types, 57.9 percent of patients in the ventilator group, 57.9 percent in the two-pressure levels group, and 47.3 percent in the CPAP group progressed with success. Oxygenation and RR variables showed improvement only in the groups with two pressure levels. CONCLUSION: Patients with hypoxemic ARF in the postoperative stage after cardiovascular surgery showed better oxygenation, RR, and HR during NIV application. In older patients and those with higher baseline RR and HR values, NIV was not sufficient to reverse ARF. The two-pressure level modes showed better results.

Tratamento alternativo na síndrome da angústia respiratória, no adulto: relato de caso / Alternative treatment in respiratory distress syndrome of adults: report of a case

Paciente do sexo feminino, de 33 anos de idade, submetida a revascularizaçao do miocárdio, aneurismectomia e trombectomia de ventrícuio esquerdo, evoluiu no pós-operatório com síndrome da angústia respiratória do adulto (SARA). Inicialmente, recebeu tratamento convencional e, pela hipoxemia persistente, optou-se pela remoçao de CO2 através de oxigenador de membrana (MACCHI-ECCO2R), associado a pressao positiva de baixa freqüência, com sucesso. A paciente permaneceu sob assistência ventilatória por 57 dias, sendo sete dias com ECCO2R. Teve alta hospitalar no 83( dia de pós-operatório. Após quatro meses, apresentava, à radiogafia pulmonar, tônus e trofismo muscular normais e espirometria com obstruçao em pequenas vias aéreas grau I.

Estudo comparativo entre CO2 obtido por capnografia e gasometria no pós-operatório de cirurgia cardíaca / Comparative study between capnography and arterial CO2 after coronary by-pass grafting

O objetivo deste estudo foi comparar a monitorização do Capnografia e análise do CO2 no sangue arterial. O estudo foi realizado no pós-operatório imediato (15 minutos após a admissão na UTI em cinquenta e cinco pacientes submetidos a revascularização do miocárdio. Conforme o valor da temperatura axilar obtida, os pacientes foram divididos em três grupos: grupo I (n = 32) temperatura maior po igual a 36ºC e grupo 3 todos os pacientes. Os resultados obtidos (média ñ desvio padrão) foram: grupo 1) CO2 sanguíneo de 27,47 ñ 5,79 mmHg, CO2 expirado de 25 ñ 6,89 mmg; grupo 2) C02 sanguineo de 30,32 ñ 6,91 mmhg, CO2 expirado de 29,22 ñ 5,32 mmhg e grupo 3) que representa todos os pacientes C02 sanguíneo de 29,18 ñ 6,03 mmHg, CO2 expirado de 27,69 ñ 6,20 mmHg. Os resultados da análise estatítica (regressão linear simples) mostraram os seguintes coeficientes de determinação: grupo 1) R2 de 0,68, grupo 2) R2 de 0,73 e grupo 3) R2 de 0,70. O teste dos parâmetros (CO2 arterial versus expirado) mostrou que apenas nos pacientes do grupo 2 os valores poderiam ser considerados iguais. Vários fatores podem explicar as difereças apontadas entre os grupos. A hipotermia, sendo um destes fatores, está relacionada com a diminuição da produção do CO2 por redução do metabolismo, aumento do espaço morto e acentuação do desequilíbrio na relação Va/Q. Embora análise estatítica não tenha mostrado comparabilidade entre os dados nos pacientes com hipotermia, os resultados sugerem que a capnografia é excelente método para monitorizar o CO2 durante ventilação artificial. Entretanto, é importante, na mesuração do CO2 expirado, a observação constante do capnograma. Dúvidas quanto ao valor real amostrado pela capnografia devem ser comprovadas com estudo gasométrico. A simples interpretação dos resultados, não se considerando aspectos clínicos relevantes, pode levar a conclusões incorretas.

Efeito da posiçäo de Trendelemburg sobre o estado hemodinâmico e a saturaçäo de oxigênio / Effect of the Trendelemburg position on hemodinamic state and the oxygen saturation

Vinte pacientes em pós-operatório de cirurgia cardíaca foram estudados com o objetivo de avaliar os efeitos da posiçäo de Trendelemburg sobre o estado hemodinâmico e a saturaçäo de oxigênio. Os pacientes foram divididos em dois grupos. No subgrupo A os pacientes estavam sob ventilaçäo mecânica, recebendo drogas vasoativas; no subgrupo B estavam respirando espontaneamente, sem uso de drogas vasoativas. Foram realizadas medidas hemodinâmicas e da saturaçäo de oxigênio (SaO2) em todos os pacientes nas posiçöes de decúbito dorsal e Trendelemburg. Os resultados obtidos comparados e analisados estatisticamente, demonstraram näo haver alteraçöes significativas nos parâmetros avaliados em ambos os grupos