Effect of Furosemide on Urinary Oxygenation in Patients with Septic Shock.

BACKGROUND: Renal medullary hypoxia precedes the development of acute kidney injury in experimental sepsis and can now be assessed by continuous measurement of urinary oxygen tension (PuO2). OBJECTIVES: We aimed to test if PuO2 measurements in patients with septic shock would be similar to those shown in experimental sepsis and would detect changes induced by the administration of furosemide. METHOD: Pilot prospective observational cohort study in a tertiary intensive care unit (ICU). Seven adult patients with septic shock admitted to ICU had PuO2 measurements recorded minutely. There were 29 episodes of intravenous furosemide (20 mg n = 19; 40 mg n = 10). RESULTS: The median pre-furosemide PuO2 was low at 21.2 mm Hg (interquartile range [IQR] 17.73-24.86) and increased to 26 mm Hg (IQR 20.27-29.95) at 20 min (p < 0.01), to 27.5 mm Hg (IQR 24.06-33.18) at 40 min (p < 0.01) and to 28.5 mm Hg (IQR 22.65-31.03) at 60 min (p < 0.01). The increase in PuO2 was greater in episodes with a diuretic response >2 mL/kg/h than during episodes without such a response (p < 0.01). CONCLUSIONS: PuO2 measurements in patients are reflective of the low values reported in experimental models of sepsis. PuO2 values increased following furosemide administration with a response independently associated with greater diuresis.

Nitric Oxide in Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials.

OBJECTIVES: To investigate the efficacy and safety of perioperative administration of nitric oxide in cardiac surgery. DESIGN: Meta-analysis of randomized controlled trials (RCTs). PARTICIPANTS: Cardiac surgery patients. INTERVENTIONS: A search of Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE for RCTs that compared nitric oxide with placebo or other comparators. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intensive care unit (ICU) stay, and secondary outcomes were mortality, duration of mechanical ventilation, and reduction of mean pulmonary artery pressure. The study included 18 RCTs comprising 958 patients. The authors calculated the pooled odds ratio (OR) and the mean difference (MD) with random-effects model. Quantitative synthesis of data demonstrated a clinically negligible reduction in the length of ICU stay (MD -0.38 days, confidence interval CI [-0.65 to -0.11]; p = 0.005) and mechanical ventilation duration (MD -4.81 hours, CI [-7.79 to -1.83]; p = 0.002) compared with all control interventions with no benefit on mortality. CONCLUSIONS: Perioperative delivery of inhaled nitric oxide resulted to be of no or minimal benefit in patients with pulmonary hypertension undergoing cardiac surgery. Large, randomized trials are needed to further assess its effect on major clinical outcomes and its cost-effectiveness.

Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial.

BACKGROUND: Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. METHODS: This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min · m) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 µg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. RESULTS: A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. CONCLUSIONS: The authors' results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.

Strategies to reduce blood transfusion: a Latin-American perspective.

PURPOSE OF REVIEW: Anemia has been demonstrated to be detrimental in several populations such as high-surgical-risk patients, critically ill elderly, and cardiac patients. Red blood cell transfusion is the most commonly prescribed therapy for anemia. Despite being life-saving, it carries a risk that ranges from mild complications to death. The aim of this review is to discuss the risks of anemia and blood transfusion, and to describe recent developments in the strategies to reduce allogeneic blood transfusion. RECENT FINDINGS: In the past decades, clinical studies comparing transfusion strategies in different populations were conducted. Despite the challenges imposed by the development of such studies, evidence-based medicine on transfusion medicine in critically ill patients is being created. Different results arising from these studies reflect population heterogeneity, specific circumstances, and difficulties in measuring the impact of anemia and transfusion in a clinical trial. SUMMARY: An adequate judgment of a clinical condition associated with proper application of the available literature is the cornerstone in the management of transfusion in critical care. Apart from this individualized strategy, the institution of a patient blood management program allows goal-directed approach through preoperative recognition of anemia, surgical efforts to minimize blood loss, and continuous assessment of the coagulation status.

Critically ill patients with COVID-19-associated acute kidney injury treated with kidney replacement therapy: Comparison between the first and second pandemic waves in São Paulo, Brazil.

INTRODUCTION: This study aimed to compare the characteristics and outcomes of critically ill patients with COVID-19-associated acute kidney injury (AKI) who were treated with kidney replacement therapy (KRT) in the first and second waves of the pandemic in the megalopolis of Sao Paulo, Brazil. METHODS: A multicenter retrospective study was conducted in 10 intensive care units (ICUs). Patients aged ≥18 years, and treated with KRT due to COVID-19-associated AKI were included. We compared demographic, laboratory and clinical data, KRT parameters and patient outcomes in the first and second COVID-19 waves. RESULTS: We assessed 656 patients (327 in the first wave and 329 in the second one). Second-wave patients were admitted later (7.1±5.0 vs. 5.6±3.9 days after the onset of symptoms, p<0.001), were younger (61.4±13.7 vs. 63.8±13.6 years, p = 0.023), had a lower frequency of diabetes (37.1% vs. 47.1%, p = 0.009) and obesity (29.5% vs. 40.0%, p = 0.007), had a greater need for vasopressors (93.3% vs. 84.6%, p<0.001) and mechanical ventilation (95.7% vs. 87.8%, p<0.001), and had higher lethality (84.8% vs. 72.7%, p<0.001) than first-wave patients. KRT quality markers were independently associated with a reduction in the OR for death in both pandemic waves. CONCLUSIONS: In the Sao Paulo megalopolis, the lethality of critically ill patients with COVID-19-associated AKI treated with KRT was higher in the second wave of the pandemic, despite these patients being younger and having fewer comorbidities. Potential factors related to this poor outcome were difficulties in health care access, lack of intra-hospital resources, delay vaccination and virus variants.

An algorithm to predict the need for invasive mechanical ventilation in hospitalized COVID-19 patients: the experience in Sao Paulo.

BACKGROUND: We aimed to characterize patients hospitalized for coronavirus disease 2019 (COVID-19) and identify predictors of invasive mechanical ventilation (IMV). METHODS: We performed a retrospective cohort study in patients with COVID-19 admitted to a private network in Sao Paulo, Brazil from March to October 2020. Patients were compared in three subgroups: non-intensive care unit (ICU) admission (group A), ICU admission without receiving IMV (group B) and IMV requirement (group C). We developed logistic regression algorithm to identify predictors of IMV. RESULTS: We analyzed 1,650 patients, the median age was 53 years (42-65) and 986 patients (59.8%) were male. The median duration from symptom onset to hospital admission was 7 days (5-9) and the main comorbidities were hypertension (42.4%), diabetes (24.2%) and obesity (15.8%). We found differences among subgroups in laboratory values obtained at hospital admission. The predictors of IMV (odds ratio and 95% confidence interval [CI]) were male (1.81 [1.11-2.94], P=0.018), age (1.03 [1.02-1.05], P<0.001), obesity (2.56 [1.57-4.15], P<0.001), duration from symptom onset to admission (0.91 [0.85-0.98], P=0.011), arterial oxygen saturation (0.95 [0.92- 0.99], P=0.012), C-reactive protein (1.005 [1.002-1.008], P<0.001), neutrophil-to-lymphocyte ratio (1.046 [1.005-1.089], P=0.029) and lactate dehydrogenase (1.005 [1.003-1.007], P<0.001). The area under the curve values were 0.860 (95% CI, 0.829-0.892) in the development cohort and 0.801 (95% CI, 0.733-0.870) in the validation cohort. CONCLUSIONS: Patients had distinct clinical and laboratory parameters early in hospital admission. Our prediction model may enable focused care in patients at high risk of IMV.

Concurrent hospitalization of a married couple presenting with distinct symptoms but diagnosed with a life-threatening infectious disease.

We described the cases of a married couple hospitalized for distinct symptoms and developed a neuroparalytic syndrome with rapid progression. In Case 1, a 75-year-old woman was admitted for abdominal pain, diarrhea, and blurred vision. The patient developed acute respiratory failure, ptosis, and ophthalmoplegia. She died on day 15 because of an acute abdomen. In Case 2, her husband, a 71-year-old man, was admitted for diplopia. The patient developed abdominal distension and slurred speech. Later, he developed bilateral ptosis, ophthalmoparesis, and mydriasis. Botulism was suspected, and both patients received botulinum antitoxin. Our male patient survived but underwent prolonged rehabilitation.

Characteristics and Risk Factors for Mortality in Critically Ill Patients with COVID-19 Receiving Invasive Mechanical Ventilation: The Experience of a Private Network in Sao Paulo, Brazil.

Introduction: The use of invasive mechanical ventilation (IMV) in COVID-19 represents in an incremental burden to healthcare systems. Aim of the study: We aimed to characterize patients hospitalized for COVID-19 who received IMV and identify risk factors for mortality in this population. Material and Methods: A retrospective cohort study including consecutive adult patients admitted to a private network in Brazil who received IMV from March to October, 2020. A bidirectional stepwise logistic regression analysis was used to determine the risk factors for mortality. Results: We included 215 patients, of which 96 died and 119 were discharged from ICU. The mean age was 62.7 ± 15.4 years and the most important comorbidities were hypertension (62.8%), obesity (50.7%) and diabetes (40%). Non-survivors had lower body mass index (BMI) (28.3 [25.5; 31.6] vs. 31.2 [28.3; 35], p<0.001, and a shorter duration from symptom onset to intubation (8.5 [6.0; 12] days vs. 10 [8.0; 12.5] days, p = 0.005). Multivariable regression analysis showed that the risk factors for mortality were age (OR: 1.07, 95% CI: 1.03 to 1.1, p < 0.001), creatinine level at the intubation date (OR: 3.28, 95% CI: 1.47 to 7.33, p = 0.004), BMI (OR: 0.91, 95% CI: 0.84 to 0.99, p = 0.033), lowest PF ratio within 48 hours post-intubation (OR: 0.988, 95% CI: 0.979 to 0.997, p = 0.011), barotrauma (OR: 5.18, 95% CI: 1.14 to 23.65, p = 0.034) and duration from symptom onset to intubation (OR: 0.76, 95% CI: 0.76 to 0.95, p = 0.006). Conclusion: In our retrospective cohort we identified the main risk factors for mortality in COVID-19 patients receiving IMV: age, creatinine at the day of intubation, BMI, lowest PF ratio 48-hours post-intubation, barotrauma and duration from symptom onset to intubation.

Acute respiratory distress syndrome following administration of gadolinium contrast agent: a case report.

BACKGROUND: Gadolinium-based contrast agents are used extensively in magnetic resonance imaging to assist diagnosis of medical conditions. Despite their documented safety profile, severe adverse events do occur, and their documentation may serve to raise the awareness of the medical community. CASE PRESENTATION: We report the case of a 15-year-old white Latin American female patient admitted to the intensive care unit for acute respiratory distress syndrome following administration of gadolinium. She did not have rash or tongue swelling but developed hypotension responsive to fluid administration and severe hypoxemia. Chest computed tomography revealed bilateral pulmonary compromise with multiple confluent consolidations. She received methylprednisolone and noninvasive ventilatory support including bilevel positive airway pressure ventilation and high-flow nasal cannula, and underwent a rapid recovery. CONCLUSION: Gadolinium-based contrast agent-induced acute respiratory distress syndrome, albeit rare, should be included in the differential diagnosis of respiratory failure shortly after magnetic resonance imaging, which is nowadays a frequent diagnostic procedure, potentially increasing the awareness of this serious complication.

Concurrent hospitalization of a married couple presenting with distinct symptoms but diagnosed with a life-threatening infectious disease

ABSTRACT We described the cases of a married couple hospitalized for distinct symptoms and developed a neuroparalytic syndrome with rapid progression. In Case 1, a 75-year-old woman was admitted for abdominal pain, diarrhea, and blurred vision. The patient developed acute respiratory failure, ptosis, and ophthalmoplegia. She died on day 15 because of an acute abdomen. In Case 2, her husband, a 71-year-old man, was admitted for diplopia. The patient developed abdominal distension and slurred speech. Later, he developed bilateral ptosis, ophthalmoparesis, and mydriasis. Botulism was suspected, and both patients received botulinum antitoxin. Our male patient survived but underwent prolonged rehabilitation.

A liberal strategy of red blood cell transfusion reduces cardiogenic shock in elderly patients undergoing cardiac surgery.

OBJECTIVE: The aim of this study was to compare outcomes in patients undergoing cardiac surgery who are aged 60 years or more or less than 60 years after implementation of a restrictive or a liberal transfusion strategy. METHODS: This is a substudy of the Transfusion Requirements After Cardiac Surgery (TRACS) randomized controlled trial. In this subgroup analysis, we separated patients into those aged 60 years or more (elderly) and those aged less than 60 years randomized to a restrictive or a liberal strategy of red blood cell transfusion. The primary outcome was a composite defined as a combination of 30-day all-cause mortality and severe morbidity. RESULTS: Of the 502 patients included in the Transfusion Requirements After Cardiac Surgery study, 260 (51.8%) were aged 60 years or more and 242 (48.2%) were aged less than 60 years and were included in this study. The primary end point occurred in 11.9% of patients in the liberal strategy group and 16.8% of patients in the restrictive strategy group (P = .254) for those aged 60 years or more and in 6.8% of patients in the liberal strategy group and 5.6% of patients in the restrictive strategy group for those aged less than 60 years (P = .714). However, in the older patients, cardiogenic shock was more frequent in patients in the restrictive transfusion group (12.8% vs 5.2%, P = .031). Thirty-day mortality, acute respiratory distress syndrome, and acute renal injury were similar in the restrictive and liberal transfusion groups in both age groups. CONCLUSIONS: Although there was no difference between groups regarding the primary outcome, a restrictive transfusion strategy may result in an increased rate of cardiogenic shock in elderly patients undergoing cardiac surgery compared with a more liberal strategy. Cardiovascular risk of anemia may be more harmful than the risk of blood transfusion in older patients.

Estudo randomizado para avaliação da terapia guiada por metas em cirurgia cardíaca de alto risco / A randomized controlled trial to evaluate goal directed therapy in high-risk patients undergoing cardiac surgery

Introdução: O objetivo do estudo foi avaliar os efeitos da terapia guiada por metas (TGM) sobre desfechos em pacientes de alto risco submetidos à cirurgia cardíaca. Métodos: Estudo prospectivo randomizado que avaliou 126 pacientes submetidos às cirurgias de revascularização do miocárdio ou valvar internados na Unidade de Terapia Intensiva Cirúrgica (UTI) do Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo. Os pacientes foram randomizados para um algoritmo de terapia guiada por metas (grupo TGM, n=62) ou grupo controle (n=64). No grupo TGM, um índice cardíaco superior a 3 L/min/m2 foi utilizado como alvo através de fluidos, inotrópicos e transfusão de concentrado de hemácias, com início após desmame da circulação extracorpórea e com término após 8 horas de admissão na UTI. Resultados: O desfecho primário foi um composto de mortalidade e complicações maiores em 30 dias. Os pacientes do grupo TGM receberam maior volume (mediana e intervalo interquartílico) de fluidos em relação ao grupo controle [1000 (625 - 1500) vs. 500 (500 - 1000) mL (P < 0,001)], e não houve diferença na administração de inotrópicos ou hemotransfusão. A incidência do desfecho primário foi menor no grupo TGM (27,4 vs. 45,3%, p=0,037). O grupo TGM apresentou menor incidência de infecção (12,9 vs. 29,7%, P=0,002) síndrome do baixo débito cardíaco (6,5 vs. 26,6%, P=0.002). Foram também observados menor dose acumulada de dobutamina (12 vs. 19 mg/Kg, P=0,003), menor tempo de internação na UTI (3 [3-4] vs. 5 [4-7] dias; P < 0,001) e no hospital (9 [8-16] vs. 12 [9-22] dias, P=0,049) no grupo TGM comparado ao grupo controle. Não houve diferença nas taxas de mortalidade em 30 dias. (4,8% vs. 9,4%, respectivamente; P = 0,492). Conclusão: A estratégia de terapia guiada por metas através de fluidos, inotrópicos e transfusão sanguínea reduziu a incidência de complicações maiores em 30 dias em pacientes de alto risco submetidos a cirurgia cardíaca.

Introduction: The objective of the study was to evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. Methods: A prospective randomized controlled trial that evaluated 126 patients undergoing coronary artery bypass or valve repair in a Surgical Intensive Care Unit (ICU) of the Heart Institute/Faculty of Medicine of University of Sao Paulo. Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (GDT group, n=62) or to usual care (n=64). In the GDT arm, a cardiac index of greater than 3 L/min/m2 was targeted with intravenous fluids, inotropes and red blood cell transfusion starting from cardiopulmonary bypass and ending eight hours after arrival to the ICU. Results: The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the GDT group received a greater median (interquartile range) volume of intra-venous fluids than the usual care group [1000 (625 - 1500) vs. 500 (500 - 1000) mL (P<0.001)], with no differences in the administration of either inotropes or red blood cell transfusions. The primary outcome was reduced in the GDT group (27.4 vs. 45.3%, p=0.037). The GDT group had a lower incidence of infection (12.9 vs. 29.7%, P=0.002) and low cardiac output syndrome (6.5 vs. 26.6%, P=0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs. 19 mg/Kg, P=0.003) and a shorter ICU (3 [3-4] vs. 5 [4-7] days; P < 0.001) and hospital length of stay (9 [8-16] vs. 12 [9-22] days, P=0.049) in the GDT compared to the usual care group. There were no differences in 30-day mortality rates (4.8% vs. 9.4%, respectively; P = 0.492). Conclusions: Goal directed therapy using fluids, inotropes and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.