Noncompliance to iodine supplementation recommendation is a risk factor for iodine insufficiency in Portuguese pregnant women: results from the IoMum cohort.

PURPOSE: After a recommendation for iodine supplementation in pregnancy has been issued in 2013 in Portugal, there were no studies covering iodine status in pregnancy in the country. The aim of this study was to assess iodine status in pregnant women in Porto region and its association with iodine supplementation. METHODS: A cross-sectional study was conducted at Centro Hospitalar Universitário São João, Porto, from April 2018 to April 2019. Pregnant women attending the 1st trimester ultrasound scan were invited to participate. Exclusion criteria were levothyroxine use, gestational age < 10 and ≥ 14 weeks, non-evolutive pregnancy at recruitment and non-signing of informed consent. Urinary iodine concentration (UIC) was measured in random spot urine by inductively coupled plasma-mass spectrometry. RESULTS: Median UIC was 104 µg/L (IQR 62-189) in the overall population (n = 481) of which 19% had UIC < 50 µg/L. Forty three percent (n = 206) were not taking an iodine-containing supplement (ICS) and median UIC values were 146 µg/L (IQR 81-260) and 74 µg/L (IQR 42-113) in ICS users and non-users, respectively (p < 0.001). Not using an ICS was an independent risk factor for iodine insufficiency [adjusted OR (95% CI) = 6.00 (2.74, 13.16); p < 0.001]. Iodised salt use was associated with increased median iodine-to-creatinine ratio (p < 0.014). CONCLUSIONS: A low compliance to iodine supplementation recommendation in pregnancy accounted for a mild-to-moderately iodine deficiency. Our results evidence the need to support iodine supplementation among pregnant women in countries with low household coverage of iodised salt. Trial registration number NCT04010708, registered on the 8th July 2019.

Guidelines for inhaled sedation in the ICU.

INTRODUCTION AND OBJECTIVES: Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY: Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS: The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION: The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.

[Usefulness of haemoperfusion in the treatment of the severe septic patient: an update]. / Utilidad de la hemoperfusión en el tratamiento del paciente séptico grave. Actualización.

Haemoperfusion is an extracorporeal technique that removes endotoxin and/or inflammatory mediators by means of an adsorptive mechanism during the passage of the blood through a porous filter. Most of the studies in the literature use polymyxin B as the adsorptive agent. This treatment is based on the assumption that the removal of endotoxin and inflammatory mediators from the circulation attenuates the inflammatory response in sepsis. This review summarizes the theoretical basis, and the experimental and clinical results published to date with the use of haemoperfusion. Although most of the studies show positive results, some doubts have arisen about the suitability of the methods described (small number of cases, low quality of the experimental design, and excessive mortality in the control groups). There are also some inconsistencies regarding the theoretical basis of its use (lack of positive effects after the removal of endotoxin from the circulation using alternative mechanisms, discrepancies regarding the best moment to initiate the therapy, unexplained beneficial effects in the absence of increased endotoxin levels). It is the opinion of the authors that haemoperfusion represents a promising therapy for the treatment of sepsis, but consider that its usefulness requires confirmation in well designed studies before being included in protocols.

Complications related to less-invasive haemodynamic monitoring.

BACKGROUND: The aim of this study was to evaluate the type and incidence of complications during insertion, maintenance, and withdrawal of central arterial catheters used for transpulmonary thermodilution haemodynamic monitoring (PiCCO™). METHODS: We conducted a prospective, observational, multicentre study in 14 European intensive care units (six countries). A total of 514 consecutive patients in whom haemodynamic monitoring by PiCCO™ was indicated were studied. RESULTS: Five hundred and fourteen PiCCO catheters (475 in femoral, 26 in radial, nine in axillary, and four in brachial arteries) were inserted. Arterial access was obtained on the first attempt in 86.4% of the patients. Minor problems such as oozing after insertion (3.3%) or removal of the catheter (3.5%) were observed, but no episodes of serious bleeding (more than 50 ml) were recorded. Small local haematomas were observed after insertion (4.5%) and after removal (1.2%) of the catheter. These complications were not more frequent in patients with coagulation abnormalities. The incidence of site inflammation and catheter-related infection was 2% and 0.78%, respectively. Other complications such as ischaemia (0.4%), pulse loss (0.4%), or femoral artery thrombosis (0.2%) were rare, transient, and all resolved with catheter removal or embolectomy, respectively. CONCLUSIONS: In this series of patients, central arterial catheters used for PiCCO™ monitoring were demonstrated to be a safe alternative for advanced haemodynamic monitoring.

Rapid response to COVID-19, escalation and de-escalation strategies to match surge capacity of Intensive Care beds to a large scale epidemic. / Respuesta rápida a COVID-19, estrategias de escalada y desescalada para ajustar la capacidad suplementaria de camas de UVI a una epidemia de gran magnitud.

BACKGROUND: A major challenge during the COVID-19 outbreak is the sudden increase in ICU bed occupancy rate. In this article we reviewed the strategies of escalation and de-escalation put in place at a large university hospital in Madrid during the COVID-19 outbreak, in order to meet the growing demand of ICU beds. MATERIALS AND METHODS: The data displayed originated from the hospital information system and the hospital contingency plan. RESULTS: The COVID-19 outbreak produced a surge of ICU patients which saturated the available ICU capacity within a few days. A total of four new ICUs had to be opened in order to accommodate all necessary new ICU admissions. Management challenges included infrastructure, material allocation and ICU staffing. Through the strategies put in place the hospital was able to generate a surge capacity of ICU beds of 340%, meet all requirements and also maintain minimal surgical activity. CONCLUSIONS: Hospital surge capacity is to date hardly quantifiable and often has to face physical limitations (material, personnel, spaces). However an extremely flexible and adaptable management strategy can help to overcome some of these limitations and stretch the system capacities during times of extreme need.

Left Hepatic Lobectomy in the Living Donor-Comparison Between Open vs Laparoscopic Surgery.

Laparoscopic hepatic surgery dramatically changed surgical practice in the last decades, improving outcomes in correctly selected patients. The reduction of postoperative pain, lower rate of complication, early return to work activities, and better esthetic result have been well described in several studies. The success of these procedures would inevitably clash in the more complex and delicate field of hepatectomy in the living donor. The 2nd International Consensus of the Conference on Laparoscopic Liver Surgery considers laparoscopic hepatectomy in the donor as an ideal procedure. The aim of this study is to compare the results between conventional and laparoscopic surgery; prospective data and retrospective analysis of 55 cases of live liver donor lobectomy were collected between January 2013 and June 2018. The mean age was 30.4 years in the video laparoscopic technique and 32.1 years in conventional surgery; the majority of donors were male in both groups. The mean time of ischemia was 70.2 minutes (range, 50-120 minutes) in laparoscopic surgery and 80.2 minutes (range, 50-165 minutes) in conventional surgery. The surgical time ranged from 270 to 800 minutes (mean, 452 minutes) in laparoscopic surgery and ranged from 300 to 600 minutes (mean, 424 minutes) in conventional surgery. The mean length of hospital stay was 2.2 days in laparoscopy and 3.97 days in conventional surgery. Laparoscopic left liver lobectomy in the living donor is safe and feasible. There was no significant difference in surgical time; however, the time of hospitalization was lower in patients submitted to laparoscopic technique.

[Hemodynamic variability caused by pressure-volume plotting and alveolar recruitment maneuvers in patients with adult respiratory distress syndrome]. / Variaciones hemodinámicas inducidas por la realización de una curva presión-volumen y una maniobra de reclutamiento alveolar en pacientes con síndrome de distrés respiratorio agudo.

OBJECTIVES: The plotting of pressure-volume curves and the performance of alveolar recruitment maneuvers are common practices in the care of patients with adult respiratory distress syndrome (ARDS), even though potentially harmful hemodynamic effects are associated with sustaining a high intrathoracic pressure. Our aim was to analyze hemodynamic and ventilatory changes related to these 2 maneuvers and to assess the short-term effectiveness of recruitment. PATIENTS AND METHODS: The patients had ARDS and were being monitored with a catheter connected to a PiCCO system. All measurements were taken in sinus rhythm and with adequate vascular filling. Values recorded during plotting of the quasistatic pressure-volume curve and the recruitment maneuver (sustained airway pressure of 40 cm H2O) were the cardiac index, mean arterial pressure, heart rate, systolic volume index, and oxygen saturation (SpO2). Blood gas measurements were recorded before the maneuvers and 15 minutes afterwards. RESULTS: All parameters decreased significantly in the 14 patients studied. The mean (SD) maximum decreases, from which all patients recovered within 2 minutes, were as follows: cardiac index, 26% (16%); mean arterial pressure, 6% (6%); heart rate, 4% (5%), systolic volume index, 21% (15%); and SpO2, 3% (3%). Significant increases in PaO2 (7% [6%]) and the ratio of PaO2 to the fraction of inspired oxygen were recorded after the recruitment maneuver (P=.016 and P=.014, respectively), but the changes were not clinically significant. CONCLUSIONS: The hemodynamic disturbances associated with the alveolar recruitment maneuver based on sustaining a high end-expiratory pressure and the minor improvement in oxygenation achieved as a result suggest that the routine use of that maneuver in ARDS patients is of questionable value.

[Bispectral index monitoring during intrahospital transport]. / Monitorización del índice biespectral en el transporte intrahospitalario.

BACKGROUND AND OBJECTIVE: Risk of morbidity and mortality increases for critically ill patients during transfers within the hospital. Such patients often require sedation, and suboptimal sedation is associated with hypertension, tachycardia, and ventilator dyssynchrony. The aim of this study was to assess level of sedation as indicated by monitoring of the bispectral (BIS) index during intrahospital transport of critical patients. PATIENTS AND METHODS: Thirty patients who required transport to the critical care unit within the hospital were studied prospectively. We recorded time in transport, the agent used for sedation and the dosage, the BIS index, mean arterial pressure (MAP), and heart rate before starting transport and upon arrival at the critical care unit. The data were recorded by an observer who was not assigned to patient care. RESULTS: The mean (SD) transport time was 13.9 (4.2) minutes. Midazolam was used in 26 patients and propofol in 4. Ten patients were given a bolus dose of cisatracurium before transfer started. Significant increases were observed in the BIS index (from 47 to 78, (P < .001), MAP (from 73 to 91 mmHg, P < .001), and heart rate (from 72 to 97 beats/min, P < .001) between the moment of starting transport and arrival at the critical care unit. Changes in the BIS index correlated significantly with changes in heart rate (r = 0.418, P = .024) but not with changes in MAP (r = 0.249, P = .19). CONCLUSIONS: Monitoring the BIS index during intrahospital transport of sedated, mechanically ventilated patients may be useful for detecting inadequate sedation.

[Relationship between mixed venous saturation and cardiac index, hemoglobin and oxygen consumption in aortic surgery]. / Relación entre la saturación venosa mixta y el índice cardíaco, la hemoglobina y el consumo de oxígeno durante la cirugía aórtica.

OBJECTIVE: Mixed venous oxygen saturation (SvO2) depends mainly on four variables: cardiac index (CI), hemoglobin concentration (Hb), arterial oxygen saturation (SpO2) and oxygen consumption (VO2). Our aim was to study the correlation between each of these variables and SvO2 during abdominal aortic surgery, a situation which is of special interest because of associated hemodynamic and metabolic variations and the high risk of cardiovascular events. PATIENTS AND METHODS: Twelve patients undergoing intrarenal aortic surgery were monitored by pulmonary artery catheter (Opticath), pulse oximetry and indirect calorimetry (Deltatrac Metabolic Monitor). SvO2, CI (measured by thermodilution), SpO2 and VO2 at six moments: post-induction (baseline), 1 min before and 1 min after clamping (pre-C, post-C), 1 min (post-D) and 10 min after declamping and at the end of the surgery. Hemoglobin concentration was measured at all moments except 10 min after declamping. RESULTS: All variables except SpO2 varied significantly (p < 0.001) during the study. SvO2 was associated with CI at all moments except post-D and at the end of surgery. Hemoglobin concentration was related to SvO2 at baseline and post-C. We found no correlation between SvO2 and VO2 or SpO2 at any moment. CONCLUSION: Monitoring SvO2 in patients undergoing aortic surgery is useful for detecting potentially prejudicial variations in cardiac output or hemoglobin concentration.

[Anesthesia in a case of Holt-Oram syndrome]. / Anestesia en un caso de síndrome de Holt-Oram.

A 19-year-old man with Holt-Oram syndrome (HOS) underwent emergency surgical treatment of an occipital abscess. He presented total aplasia of the radius and first and second finger of the left hand, asymmetric thorax and complex cyanotic cardiopathy with double output of the right ventricle that had been treated on several occasions, malpositioning of the large vessels and interventricular conduction. He had been treated with digoxin for episodes of supraventricular tachycardia. After premedication with 0.4 mg of atropine, balanced general anesthesia was induced with etomidate and remifentanil and maintained with O2/air/desflurane and infused remifentanil. The patient remained hemodynamically stable during surgery and tubes were removed in the operating room with no complications. HOS, a hereditary disease characterized by congenital malformations of the upper extremities and the heart, is often associated with rhythm disorders. Problems that may develop in such patients during anesthesia include difficulty catheterizing vessels, difficult orotracheal intubation and ventilation, hemodynamic instability, and the presentation of arrhythmias and cardiac arrest.

Effects of extracts of selected medicinal plants upon hepatic oxidative stress.

Aqueous extracts of a few medicinal plants traditionally used in Portugal have been assayed for their effects upon hepatic oxidative stress in mice. Previous in vitro studies had allowed characterization of agrimony, sage, savory, and raspberry in terms of overall antioxidant capacity and phenolic content. In the present study, the antioxidant effect and safety of these four plants were evaluated in vivo. For this purpose, mice ingested extracts in aqueous form (or water, used as the control) for 4 weeks; damage to lipids, proteins, and DNA was evaluated by oxidative cell biomarkers by the end of that period. Levels of hepatic glutathione and activities of enzymes involved in metabolism thereof were also determined. Finally, catalase and superoxide dismutase (SOD) activities were quantified, as these enzymes play a crucial role in antioxidant defense. When compared with the control, both raspberry and savory produced significant lipid protection; however, protein damage was significantly lower only in raspberry-treated animals. On the other hand, DNA damage was prevented only by savory. All plants led to a decrease in catalase activity, whereas all but sage also produced a decrease in SOD activity. With regard to glutathione levels and activities of enzymes involved in its metabolism, the aforementioned extracts exhibited different effects. In general, raspberry appeared to be the most promising extract, followed by savory, sage, and agrimony, sorted by decreasing performance in protection; the latter was even slightly toxic. Hence, the plants tested possess compounds with interesting biological activities that may support eventual inclusion in food or feed as functional additives.

Monitoring sedation in critically ill patients: bispectral index, Ramsay and observer scales.

BACKGROUND AND OBJECTIVE: Sedation is commonly required by critically ill patients and inadequate sedation may be hazardous. Traditionally, subjective scales have been used for monitoring sedation. Bispectral index has been proposed, although its utility in the intensive care unit is debated. Our aim was to evaluate the depth of sedation in intubated surgical critically ill patients by means of two sedation scales (Ramsay and Observer's Assessment of Alertness and Sedation) and bispectral index. METHODS: Sedation was assessed prospectively in 50 postoperative intubated patients requiring at least 24 h of sedation (35 propofol, 15 midazolam/fentanyl), every 8 h for a 24 -h period. The bispectral index value recorded was the mean value obtained during a 10-min observation period, whenever the quality signal index was above 75% and the electromyographic signal was below 25%. RESULTS: Most of the patients (78%) were oversedated (bispectral index < 60). The three sedation scores (global data) correlated significantly (P < 0.001). This correlation was lost in the midazolam group in which the patients were also significantly more sedated than the propofol group (P = 0.001). The correlation between the bispectral index and the scales in the midazolam group reappeared when the measurements with a Ramsay = 6 or an Observer's Assessment of Alertness and Sedation = 1 were excluded. CONCLUSIONS: Sedation should be monitored routinely in intensive care units. The Ramsay and the Observer's Assessment of Alertness and Sedation scales showed equal efficacy. Bispectral index might prove useful for discriminating between deeper levels of sedation.

Pressure-volume curve variations after a recruitment manoeuvre in acute lung injury/ARDS patients: implications for the understanding of the inflection points of the curve.

BACKGROUND AND OBJECTIVE: Although the pressure-volume (P-V) curve has been proposed in the management of mechanically ventilated patients, its interpretation remains unclear. Our aim has been to study the variations of the P-V curve after a recruitment manoeuvre (RM). Our hypothesis was that the lower inflection point (LIP) represents the presence of compressive atelectases, so it should not change after lung recruitment, while the upper inflection point (UIP) reflects reabsorptive atelectases, and an effective recruitment should result in changes at this level. METHODS: Two P-V curves (quasi-static method) separated by an RM (40 cmH2O, two consecutive manoeuvres) were plotted in 35 postoperative patients with criteria of acute lung injury/acute respiratory distress syndrome (ARDS). LIP, UIP and expiratory inflection point (EIP) were defined as the first point where the curve consistently starts to separate from the line. RESULTS: One to six measurements were obtained per patient (73 procedures). Neither the lower nor the EIPs varied significantly after the RM (P = 0.11 and 0.35, respectively). An UIP was observed in 18 curves (25%) before the RM and disappeared on nine occasions after the recruitment. Similar results were obtained when first measurements only were analysed, and when the cause (pulmonary vs. extrapulmonary), severity of lung injury or duration of mechanical ventilation at first measurement were studied. CONCLUSIONS: An RM does not modify the LIP significantly, but induces the disappearance of the UIP in 50% of the cases in which this point is found.

Calculated versus measured oxygen consumption during aortic surgery: reliability of the Fick method.

Oxygen consumption (VO2) can be obtained by the Fick method as the product of cardiac index (CI) by the arteriovenous oxygen content difference (D[a-v]O2) or by indirect calorimetry (IC) based on gas exchange measurements. IC is considered the "gold standard" but is not widely available in clinical practice. Our objective was to test the reliability of the reversed Fick method compared with IC under conditions of hemodynamic changes. For this purpose we chose aortic clamping and unclamping as a model. Twelve patients undergoing abdominal aortic surgery were monitored with a fiberoptic pulmonary artery catheter (Opticath). Calculated oxygen consumption (cVO2) was obtained from hemodynamic and analytic data according to the Fick method at six stages: postinduction, before cross-clamping (Pre-C), postclamping (Post-C), before unclamping (Pre-U), after unclamping (Post-U), and the end of surgery. cVO2 was compared with measured oxygen consumption (mVO2) obtained by IC. CI and mixed venous oxygen saturation (SVO2) varied significantly (P < 0.0001) during the interventions. Although mVO2 did not vary, cVO2 varied significantly (P = 0.0001), reaching a maximum at Post-U coinciding with a sudden decrease in SVO2. There was good concordance between mVO2 and cVO2 except at Post-U (P = 0.005). We conclude that cVO2 is a reliable indicator of VO2 in this hemodynamic model except at Post-U. This lack of correlation seems to be due to a mathematical artifact, because the low value of SVO2 registered at this stage and introduced into the Fick formula reflects a sudden venous return of desaturated blood and not an increase in VO2.

[Acute toxicity of ammonia to Artemia sp]. / Toxicidade aguda da amônia para Artemia sp.

The acute toxicity of total ammonia-N, (NH3 + NH4+), and un-ionized ammonia-N, NH3-N, on newly hatched Artemia nauplii and Artemia adults was measured in 24, 48, 72, and 96-h semi-static bioassays system. There was a significant difference (P < 0.05) in medial lethal concentrations (LC50) obtained during the tests. The LC50 values on nauplii ranged from 650 mg/l, in 24-h, to 399.1 mg/l total ammonia-N, in 96-h, while the LC50 values on adults ranged from 1290.4 mg/l to 600.5 mg/l total ammonia-N, in the same period. Two methods for calculations of un-ionized ammonia toxicity are analyzed and discussed.

Metabolic pattern and lipid oxidation during abdominal surgery: midazolam versus propofol.

Propofol is formulated in an emulsion similar to 10% Intralipid, and several authors have suggested that fat accumulates during its infusion. In this study we used indirect calorimetry to measure lipid metabolism during abdominal surgery in patients anesthetized with propofol, using midazolam as a control. Thirty patients were randomly divided into three groups: Group P (propofol 2 mg/kg + 5 mg.kg-1.h-1, n = 13); Group M (midazolam, n = 9), and Group I (midazolam + 10% Intralipid at rates similar to those infused in Group P, n = 8). They were monitored with an indirect calorimeter for 90 min. Data including oxygen consumption (VO2), CO2 production (VCO2), energy expenditure (EE), respiratory quotient (RQ), and lipid utilization were obtained every 15 min. VO2 increased in all groups at 45 min in respect to basal measurements with no differences between them. VCO2 decreased significantly only in Groups P and I, although no differences between the three groups were observed. EE did not vary in any of the groups. RQ decreased in all groups at 30 min, being significantly higher in Group M than in Groups P and I. Lipid oxidation increased in all groups from the beginning of the study reaching a plateau at 45 min. The lipid oxidation was higher in Groups P and I than in Group M, and coincided (80-100 g/24 h) with the amount of fat administered exogenously (85.4 g/ 24 h for a patient of 70 kg). Compared to VO2, VCO2, and EE, propofol behaves as other anesthetics. The fat administered in its formulation is metabolized in a preferential way, although it is likely that larger doses than those studied in our patients partially accumulate.

Arsenic mononucleotides. Separation by high-performance liquid chromatography and identification with myokinase and adenylate deaminase.

The spontaneous formation of arsenic mononucleotides has been detected in mixtures of arsenate and inosine or adenosine or its deoxy analogues. These compounds have been separated by high-performance liquid chromatography and identified by their behavior in the presence of myokinase and adenylate deaminase. The nucleoside 5'-arsenates are formed preferentially to the 2'- and 3'-arsenate analogues. All arsenic nucleotides detected showed similar kinetic and equilibrium constants of formation: about 8 X 10(-4) M-1 S-1 and 2 X 10(-3) M-1, respectively. These values are several orders of magnitude greater than those of their phosphoric analogues. The adenosine 5'-arsenate was able to substitute for 5'AMP in the reaction of myokinase and adenylate deaminase. The substitutions of the 2'- or 3'-hydrogen for hydroxyl groups in the ribose moiety of this compound slightly affected its suitability as substrate for myokinase but had drastic effect in the case of adenylate deaminase. The half-life of the arsenic nucleotides, at pH 7.0 and 25 degrees C, ranged from 30 to 45 min. The lability of these compounds is increased during catalysis with myokinase. Results on the reaction mechanism of myokinase with adenosine 5'-arsenate indicate that the mixed-anhydride analogue to ADP, adenosine 5'-(arsenate phosphate), is not detected either because it is not formed in the reaction with this enzyme or because it is rapidly hydrolyzed.

[The work of the nurse in administering cytostatics to the leukemic child]. / Labor de la enfermera en la administración de citostáticos en el niño leucémico.

This study consisted in the observation of the technique of administration of antineoplastic drugs to children in the Department of Hematology and Oncology at "Pedro Borrás Astorga" Pediatric Hospital during January and February, 1989. A number of 50 techniques from which 96% were correct and only two (4%) were incorrect since there was a chemical phlebitis in the site of the venous puncture, was observed. It was proved that nursing staff is well trained for the development of this technique which requires maximal scientific skills to avoid complications in these patients. Adverse reactions shown by the patients with the administration of different antineoplastic drugs do not differ from what has been found in the literature.