Cerebral blood flow changes during intermittent acute hypoxia in patients with heart failure.

Objective Heart failure (HF) is associated with intermittent hypoxia, and the effects of this hypoxia on the cardiovascular system are not well understood. This study was performed to compare the effects of acute hypoxia (10% oxygen) between patients with and without HF. Methods Fourteen patients with chronic HF and 17 matched control subjects were enrolled. Carotid artery changes were examined during the first period of hypoxia, and brachial artery changes were examined during the second period of hypoxia. Data were collected at baseline and after 2 and 4 minutes of hypoxia. Norepinephrine, epinephrine, dopamine, and renin were measured at baseline and after 4 minutes hypoxia. Results The carotid blood flow, carotid systolic diameter, and carotid diastolic diameter increased and the carotid resistance decreased in patients with HF. Hypoxia did not change the carotid compliance, distensibility, brachial artery blood flow and diameter, or concentrations of sympathomimetic amines in patients with HF, but hypoxia increased the norepinephrine level in the control group. Hypoxia increased minute ventilation and decreased the oxygen saturation and end-tidal carbon dioxide concentration in both groups. Conclusion Hypoxia-induced changes in the carotid artery suggest an intensification of compensatory mechanisms for preservation of cerebral blood flow in patients with HF.

Goal-directed therapy for decompensated heart failure and renal dysfunction. A pilot randomized clinical trial / Terapia alvo-dirigida para insuficiência cardíaca descompensada e disfunção renal: um estudo-piloto clínico randomizado

OBJECTIVES: Acute heart failure is associated with low cardiac output syndrome and renal dysfunction. However, it is not known whether a goal-directed protocol guided by tightly controlled hemodynamic variables, including pulmonary artery catheter, will safely improve clinical renal dysfunction markers in these patients when compared to a less invasive approach. METHODS: Pilot, randomized clinical trial aimed at patients with known heart failure, low cardiac output syndrome and renal dysfunction with less than 48 hours from onset. We randomized two groups: (a) goal-directed therapy monitored with pulmonary artery catheter and (b) conventional therapy with central venous catheter. Hemodynamic parameters, venous oxygen saturation, serum lactate, fluid repositions and vasoactive drugs were compared considering renal function improvement after 72 hours as the primary study endpoint. We included 15 goal-directed therapy and 16 conventional therapy patients. The study has assessed patients on baseline looking for significant improvement at 72 hours of the following parameters in the goal-directed therapy and conventional therapy groups: urine output, serum creatinine, venous oxygen saturation and serum lactate. RESULTS: Baseline characteristics were similar in both groups. In the first 24 hours there was a lower volume of fluid reposition in the goal-directed therapy group, although 72 hours later such reposition was equivalent. The use of inotropic agents was similar between groups. There was an improvement to the renal function and the hemodynamic parameter in both study groups. CONCLUSIONS: The option for the protocol with pulmonary artery catheter setting is justified only if there is clinical evidence of serious pulmonary congestion associated to low peripheral perfusion.

OBJETIVOS: A Insuficiência cardíaca aguda está associada à síndrome de baixo débito cardíaco e disfunção renal. No entanto, não se sabe se o protocolo meta-dirigido guiado por variáveis hemodinâmicas rigorosamente controladas, incluindo cateter de artéria pulmonar, irá melhorar de forma segura os marcadores de disfunção renal clínica nestes pacientes, quando comparados a uma abordagem menos invasiva. MÉTODOS: Ensaio clínico piloto randomizado incluindo pacientes com insuficiência cardíaca conhecida, síndrome de baixo débito cardíaco e disfunção renal com menos de 48 horas de evolução. Foram randomizados dois grupos: terapia alvo-dirigida monitorada com cateter de artéria pulmonar e terapia convencional com cateter venoso central. Os parâmetros hemodinâmicos, a saturação venosa, o lactato sérico, o volume de reposição de fluidos e as doses de drogas vasoativas foram comparados, considerando a melhora da função renal após 72 horas como o desfecho primário do estudo. RESULTADOS: Foram incluídos 15 pacientes no grupo de terapia alvo-dirigida e 16 pacientes em terapia convencional. As características basais foram semelhantes em ambos os grupos. O estudo avaliou os seguintes parâmetros dos pacientes na linha de base e após 72 horas para os dois grupos: excreção urinária, creatinina sérica, saturação venosa de oxigênio e lactato. Nas primeiras 24 horas houve menor reposição de fluido no grupo de terapia dirigida mas, ao fim de 72 horas, a reposição tornou-se equivalente. O uso de agentes inotrópicos foi semelhante entre os grupos. CONCLUSÕES: Houve uma melhora da função renal e dos parâmetros hemodinâmicos em ambos os grupos de estudo. A opção para o protocolo com cateter de artéria pulmonar só se justifica se houver evidência clínica de congestão pulmonar grave associada à baixa perfusão periférica.

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry / Terapia de Contrapulsação Aórtica em Pacientes com Insuficiência Cardíaca Avançada: Análise do Registro TBRIDGE

Abstract Background: The use of aortic counterpulsation therapy in advanced heart failure is controversial. Objectives: To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure. Methods: Historical prospective, unicentric study to evaluate all patients treated with IABP betwen August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO2), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and diferences in subgroups were evaluated by the Log-rank test. Results: A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO2 (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008). Conclusion: After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.

Resumo Fundamento: A utilização da terapia de contrapulsação aórtica na insuficiência cardíaca avançada é controversa. Objetivos: Avaliar o efeito hemodinâmico e metabólico do balão intra-aórtico (BIA) e seu impacto sobre a mortalidade em 30 dias em pacientes com insuficiência cardíaca. Métodos: Estudo prospectivo histórico, unicêntrico, avaliando todos os pacientes tratados com BIA entre agosto/2008 e julho/2013, incluídos em registro institucional denominado TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). Analisaram-se variações na saturação venosa central de oxigênio (SVO2), lactato arterial e uso de fármacos vasoativos 48 horas após instalação do dispositivo. A mortalidade em 30 dias foi estimada pelo método de Kaplan-Meier e diferenças entre subgrupos foram avaliadas pelo teste de Log-rank. Resultados: Foram incluídos 223 pacientes com idade média de 49 ± 14 anos, fração de ejeção do ventrículo esquerdo média de 24 ± 10%, sendo 30% acometidos por Doença de Chagas. Em comparação à pré-instalação do BIA, após a instalação, houve aumento da SVO2 (51% vs. 66%, p < 0,001) e no uso de nitroprussiato (34% vs. 48%, p < 0,001), além de redução do lactato (31 vs. 17 mg/dL, p < 0,001) e no uso de vasopressores (36% vs. 26%, p = 0,003). A sobrevida em 30 dias foi de 69%, com menor mortalidade nos pacientes chagásicos comparativamente aos não chagásicos (p = 0,008). Conclusão: Nas primeiras 48 horas de utilização, o BIA promoveu mudança no uso de fármacos vasoativos e melhora da perfusão tecidual. A etiologia chagásica associou-se a menor mortalidade em 30 dias. A terapia de contrapulsação aórtica mostrou-se opção eficaz de suporte circulatório em pacientes candidatos a transplante cardíaco.

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry.

BACKGROUND: The use of aortic counterpulsation therapy in advanced heart failure is controversial. OBJECTIVES: To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure. METHODS: Historical prospective, unicentric study to evaluate all patients treated with IABP between August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO2), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and differences in subgroups were evaluated by the Log-rank test. RESULTS: A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO2 (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008). CONCLUSION: After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.

I guideline for cardiopulmonary resuscitation and emergency cardiovascular care -- Brazilian Society of Cardiology: executive summary.

Despite advances related to the prevention and treatment in the past few years, many lives are lost to cardiac arrest and cardiovascular events in general in Brazil every year. Basic Life Support involves cardiovascular emergency treatment mainly in the pre-hospital environment, with emphasis on the early recognition and delivery of cardiopulmonary resuscitation maneuvers focused on high-quality thoracic compressions and rapid defibrillation by means of the implementation of public access-to-defibrillation programs. These aspects are of the utmost importance and may make the difference on the patient's outcomes, such as on hospital survival with no permanent neurological damage. Early initiation of the Advanced Cardiology Life Support also plays an essential role by keeping the quality of thoracic compressions; adequate airway management; specific treatment for the different arrest rhythms; defibrillation; and assessment and treatment of the possible causes during all the assistance. More recently, emphasis has been given to post-resuscitation care, with the purpose of reducing mortality by means of early recognition and treatment of the post-cardiac arrest syndrome. Therapeutic hypothermia has provided significant improvement of neurological damage and should be performed in comatose individuals post-cardiac arrest. For physicians working in the emergency department or intensive care unit, it is extremely important to improve the treatment given to these patients by means of specific training, thus giving them the chance of higher success and of better survival rates.

I diretriz de ressuscitação cardiopulmonar e cuidados cardiovasculares de emergência da Sociedade Brasileira de Cardiologia: resumo executivo / I guideline for cardiopulmonary resuscitation and emergency cardiovascular care - Brazilian Society of Cardiology: executive summary

Apesar de avanços nos últimos anos relacionados à prevenção e a tratamento, muitas são as vidas perdidas anualmente no Brasil relacionado à parada cardíaca e a eventos cardiovasculares em geral. O Suporte Básico de Vida envolve o atendimento às emergências cardiovasculares principalmente em ambiente pré-hospitalar, enfatizando reconhecimento e realização precoces das manobras de ressuscitação cardiopulmonar com foco na realização de compressões torácicas de boa qualidade, assim como na rápida desfibrilação, por meio da implementação dos programas de acesso público à desfibrilação. Esses aspectos são de fundamental importância e podem fazer diferença no desfecho dos casos como sobrevida hospitalar sem sequelas neurológicas. O início precoce do Suporte Avançado de Vida em Cardiologia também possui papel essencial, mantendo, durante todo o atendimento, a qualidade das compressões torácicas, adequado manejo da via aérea, tratamento específico dos diferentes ritmos de parada, desfibrilação, avaliação e tratamento das possíveis causas. Mais recentemente dá-se ênfase a cuidados pós-ressuscitação, visando reduzir a mortalidade por meio do reconhecimento precoce e tratamento da síndrome pós-parada cardíaca. A hipotermia terapêutica tem demonstrado melhora significativa da lesão neurológica e deve ser realizada em indivíduos comatosos pós-parada cardíaca. Para os médicos que trabalham na emergência ou unidade de terapia intensiva é de grande importância o aperfeiçoamento no tratamento desses pacientes por meio de treinamentos específicos, possibilitando maiores chances de sucesso e maior sobrevida.

Despite advances related to the prevention and treatment in the past few years, many lives are lost to cardiac arrest and cardiovascular events in general in Brazil every year. Basic Life Support involves cardiovascular emergency treatment mainly in the pre-hospital environment, with emphasis on the early recognition and delivery of cardiopulmonary resuscitation maneuvers focused on high-quality thoracic compressions and rapid defibrillation by means of the implementation of public access-to-defibrillation programs. These aspects are of the utmost importance and may make the difference on the patient's outcomes, such as on hospital survival with no permanent neurological damage. Early initiation of the Advanced Cardiology Life Support also plays an essential role by keeping the quality of thoracic compressions; adequate airway management; specific treatment for the different arrest rhythms; defibrillation; and assessment and treatment of the possible causes during all the assistance. More recently, emphasis has been given to post-resuscitation care, with the purpose of reducing mortality by means of early recognition and treatment of the post-cardiac arrest syndrome. Therapeutic hypothermia has provided significant improvement of neurological damage and should be performed in comatose individuals post-cardiac arrest. For physicians working in the emergency department or intensive care unit, it is extremely important to improve the treatment given to these patients by means of specific training, thus giving them the chance of higher success and of better survival rates.

Electric ventilation: indications for and technical aspects of diaphragm pacing stimulation surgical implantation.

OBJECTIVE: Patients with high cervical spinal cord injury are usually dependent on mechanical ventilation support, which, albeit life saving, is associated with complications and decreased life expectancy because of respiratory infections. Diaphragm pacing stimulation (DPS), sometimes referred to as electric ventilation, induces inhalation by stimulating the inspiratory muscles. Our objective was to highlight the indications for and some aspects of the surgical technique employed in the laparoscopic insertion of the DPS electrodes, as well as to describe five cases of tetraplegic patients submitted to the technique. METHODS: Patient selection involved transcutaneous phrenic nerve studies in order to determine whether the phrenic nerves were preserved. The surgical approach was traditional laparoscopy, with four ports. The initial step was electrical mapping in order to locate the "motor points" (the points at which stimulation would cause maximal contraction of the diaphragm). If the diaphragm mapping was successful, four electrodes were implanted into the abdominal surface of the diaphragm, two on each side, to stimulate the branches of the phrenic nerve. RESULTS: Of the five patients, three could breathe using DPS alone for more than 24 h, one could do so for more than 6 h, and one could not do so at all. CONCLUSIONS: Although a longer follow-up period is needed in order to reach definitive conclusions, the initial results have been promising. At this writing, most of our patients have been able to remain ventilator-free for long periods of time.

Ventilação elétrica: indicações e aspectos técnicos do implante cirúrgico do marca-passo de estimulação diafragmática / Electric ventilation: indications for and technical aspects of diaphragm pacing stimulation surgical implantation

OBJETIVO: Pacientes com lesão medular cervical alta em geral são dependentes de ventilação mecânica, que, embora salve vidas, está associada a complicações e redução da expectativa de vida devido a infecções respiratórias. A estimulação do diafragma por marca-passo, às vezes chamada de ventilação elétrica, induz a inspiração por estimulação dos músculos inspiratórios. Nosso objetivo foi destacar as indicações e alguns aspectos da técnica cirúrgica empregada no implante laparoscópico dos eletrodos, assim como descrever cinco casos de pacientes tetraplégicos submetidos à técnica. MÉTODOS: A seleção dos pacientes envolveu estudos de condução do nervo frênico por via transcutânea para determinar se os nervos estavam preservados. A abordagem cirúrgica foi laparoscopia clássica, com quatro trocartes. A técnica foi iniciada com o mapeamento elétrico para encontrar os "pontos motores" (pontos de contração máxima do diafragma). Se o mapeamento era bem-sucedido, dois eletrodos eram implantados na face abdominal de cada lado do diafragma para estimular ramos do nervo frênico. RESULTADOS: Dos cinco pacientes, três e um, respectivamente, eram capazes de respirar somente com o uso do marca-passo por períodos superiores a 24 e 6 h, enquanto um não era capaz. CONCLUSÕES: Embora seja necessário um acompanhamento mais longo para chegar a conclusões definitivas, os resultados iniciais são promissores, pois, no momento, a maioria dos nossos pacientes pode permanecer sem ventilação mecânica por longos períodos de tempo.

OBJECTIVE: Patients with high cervical spinal cord injury are usually dependent on mechanical ventilation support, which, albeit life saving, is associated with complications and decreased life expectancy because of respiratory infections. Diaphragm pacing stimulation (DPS), sometimes referred to as electric ventilation, induces inhalation by stimulating the inspiratory muscles. Our objective was to highlight the indications for and some aspects of the surgical technique employed in the laparoscopic insertion of the DPS electrodes, as well as to describe five cases of tetraplegic patients submitted to the technique. METHODS: Patient selection involved transcutaneous phrenic nerve studies in order to determine whether the phrenic nerves were preserved. The surgical approach was traditional laparoscopy, with four ports. The initial step was electrical mapping in order to locate the "motor points" (the points at which stimulation would cause maximal contraction of the diaphragm). If the diaphragm mapping was successful, four electrodes were implanted into the abdominal surface of the diaphragm, two on each side, to stimulate the branches of the phrenic nerve. RESULTS: Of the five patients, three could breathe using DPS alone for more than 24 h, one could do so for more than 6 h, and one could not do so at all. CONCLUSIONS: Although a longer follow-up period is needed in order to reach definitive conclusions, the initial results have been promising. At this writing, most of our patients have been able to remain ventilator-free for long periods of time.

Atrioventricular block pathology in cardiomyopathy by desmin deposition.

Generally, restrictive cardiomyopathy due to desmin deposition is characterized by restriction to ventricular diastolic filling and different degrees of atrioventricular block (AVB). In this report, we describe the pathological changes of the cardiac conduction system related to AVB. The sinus node, the compact node, and the penetrating bundle (bundle of His) had no abnormalities, however, there was extensive fibrosis of the terminal portions of the branching bundle and the beginning of the left and right bundles at the top of the ventricular septum. The pathogenesis of this fibrous replacement is probably the same that leads to extensive fibrosis of the working ventricular myocardium, and remains to be elucidated.

Patologia do bloqueio atrioventricular na cardiomiopatia por depósito de desmina / Atrioventricular block pathology in cardiomyopathy by desmin deposition / Patología de bloqueo auriculoventricular en la miocardiopatía por depósito de desmina

Geralmente, a cardiomiopatia restritiva por deposição de desmina é caracterizada pela restrição ao enchimento diastólico ventricular e por diferentes graus de bloqueio atrioventricular (BAV). Neste relato, são descritas as alterações anatomopatológicas do sistema de condução cardíaco relacionadas ao BAV. O nó sinusal, o nó compacto e o feixe penetrante (feixe de His) não apresentavam anormalidades, entretanto, havia extensa fibrose das porções terminais do feixe ramificante e do início dos feixes esquerdo e direito, no topo do septo ventricular. A patogenia dessa substituição fibrosa é provavelmente a mesma que origina a extensa fibrose do miocárdio ventricular contrátil, e permanece por ser elucidada.

Generally, restrictive cardiomyopathy due to desmin deposition is characterized by restriction to ventricular diastolic filling and different degrees of atrioventricular block (AVB). In this report, we describe the pathological changes of the cardiac conduction system related to AVB. The sinus node, the compact node, and the penetrating bundle (bundle of His) had no abnormalities, however, there was extensive fibrosis of the terminal portions of the branching bundle and the beginning of the left and right bundles at the top of the ventricular septum. The pathogenesis of this fibrous replacement is probably the same that leads to extensive fibrosis of the working ventricular myocardium, and remains to be elucidated.

En general, la miocardiopatía restrictiva, debido a la deposición de desmina se caracteriza por la restricción de llenado diastólico ventricular y por los distintos grados de bloqueo auriculoventricular (BAV). En este informe, se describen los cambios anatómicos y patológicos del sistema de conducción cardiaco relacionado con BAV. El nodo sinusal, el nodo compacto y haz penetrante (haz de His) no tuvo alteraciones, sin embargo, había fibrosis extensa de las porciones terminales del haz en porción ramificante y del comienzo de los haces izquierda y derecha, en la parte superior del tabique ventricular. La patogenia de esta sustitución fibrosa es probablemente la misma que origina la fibrosis extensa del miocardio ventricular contráctil, y queda por dilucidar.

Avaliação nutricional do cardiopata crítico em terapia de substituição renal: dificuldade diagnóstica / Nutritional assessment of the critically ill patients with cardiac disease under renal replacement therapy: diagnostic difficulty

OBJETIVO: Realizar avaliação nutricional em pacientes cardiopatas críticos que necessitem de terapia de substituição renal. MÉTODOS: Pacientes cardiopatas críticos, internados em unidade de terapia intensiva, que apresentavam insuficiência renal com indicação de terapia de substituição renal foram submetidos à avaliação nutricional com a utilização de medidas antropométricas e análise laboratorial. RESULTADOS: Foram avaliados 43 pacientes, com idade de 64±15 anos, 26 do sexo masculino. A média da fração de ejeção do ventrículo esquerdo foi de 0,36±0,16. Avaliação do estado nutricional com base no índice de massa corpórea revelou 18 pacientes eutróficos, 6 pacientes com baixo peso, 19 pacientes com sobrepeso ou obesidade. Baseado na medida da prega cutânea tricipital, 16 pacientes eram eutróficos, 27 pacientes apresentaram algum grau de depleção e, com base na circunferência do braço e na circunferência muscular do braço, 41 pacientes apresentaram algum grau de depleção. Dados laboratoriais evidenciaram depleção grave baseado na albumina em 28 pacientes e 27 pacientes tinham depleção grave de acordo com a contagem de linfócitos. CONCLUSÃO: A desnutrição é comum em pacientes cardiopatas críticos em terapia de substituição renal. Avaliação nutricional baseada no índice de massa corpórea não revelou ser bom método para diagnóstico de distúrbios nutricionais nesta população. Há necessidade de complementar a avaliação nutricional para identificação de desnutrição e possibilitar introdução precoce de suporte nutricional adequado.

OBJECTIVE: Evaluate the nutritional status of patients with cardiac disease and concomitant renal dysfunction requiring renal replacement therapy. METHODS: Patients with cardiac disease and renal failure receiving renal replacement therapy, admitted to an intensive care unit, were submitted to nutritional evaluation, by use of anthropometric measurements and laboratory data. RESULTS: We studied 43 patients, mean age 64±15 years, 26 were men. The mean left ventricular ejection fraction was 0.36±0.16. Analysis of anthropometric measurements, based on body mass index disclosed that, 18 patients were normal, 6 were underweight and 19 were overweight or obese. Based on measurement of triceps skinfold thickness, 16 patients were considered normal and 27 had some degree of depletion. Measurements of midarm circumference and midarm muscular circumference showed 41 patients with some degree of depletion. Laboratory data revealed 28 patients with depletion based on albumin levels and 27 with depletion based on lymphocyte count. CONCLUSIONS: Malnutrition is common in critically ill patients with cardiac disease and renal failure receiving renal replacement therapy. Nutritional assessment based on body mass index did not prove to be a good index for diagnosis of nutritional disorders. The nutritional evaluation must be complemented in order to identify malnutrition and introduce early nutritional support.

Nutritional assessment of the critically ill patients with cardiac disease under renal replacement therapy: diagnostic difficulty. / Avaliação nutricional do cardiopata crítico em terapia de substituição renal: dificuldade diagnóstica.

OBJECTIVE: Evaluate the nutritional status of patients with cardiac disease and concomitant renal dysfunction requiring renal replacement therapy. METHODS: Patients with cardiac disease and renal failure receiving renal replacement therapy, admitted to an intensive care unit, were submitted to nutritional evaluation, by use of anthropometric measurements and laboratory data. RESULTS: We studied 43 patients, mean age 64±15 years, 26 were men. The mean left ventricular ejection fraction was 0.36±0.16. Analysis of anthropometric measurements, based on body mass index disclosed that, 18 patients were normal, 6 were underweight and 19 were overweight or obese. Based on measurement of triceps skinfold thickness, 16 patients were considered normal and 27 had some degree of depletion. Measurements of midarm circumference and midarm muscular circumference showed 41 patients with some degree of depletion. Laboratory data revealed 28 patients with depletion based on albumin levels and 27 with depletion based on lymphocyte count. CONCLUSIONS: Malnutrition is common in critically ill patients with cardiac disease and renal failure receiving renal replacement therapy. Nutritional assessment based on body mass index did not prove to be a good index for diagnosis of nutritional disorders. The nutritional evaluation must be complemented in order to identify malnutrition and introduce early nutritional support.

Desafios na profilaxia do tromboembolismo venoso: abordagem do paciente crítico / Challenges in prevention venous thromboembolism: critical ill patient approach

JUSTIFICATIVA E OBJETIVOS: O tromboembolismo venoso (TEV), que inclui a trombose venosa profunda (TVP) e o tromboembolismo pulmonar (TEP) são complicações comuns em pacientes críticos. A ocorrência de TEV acarreta um substancial aumento da morbimortalidade dos pacientes internados em unidades de terapia intensiva (UTI). CONTEÚDO: A maioria dos pacientes críticos apresenta alto risco para ocorrência de complicações tromboembólicas, entretanto, a prevenção do TEV muitas vezes não é realizada de maneira adequada para este grupo de pacientes. A heparina de baixo peso molecular (HBPM) parece ser o método mais eficiente para a prevenção do TEV em pacientes de UTI. Entretanto, é patente a escassez de estudos voltados para esta população, cujas particularidades levam a recomendações específicas em relação ao diagnóstico e tratamento. CONCLUSÕES: Esta revisão faz uma análise do risco, discute os principais trabalhos publicados a respeito da profilaxia e sugere estratégias para a diminuição da ocorrência de TEV nos pacientes críticos.

BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE), with includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication in critically ill patients, resulting in high morbidity and mortality. CONTENTS: Most patients treated in intensive care units (ICU) face a high risk of thromboembolic complications. Despite these considerations, the prevention of VTE may not be as high a priority in ICU patients as it is in other high-risk patient groups. Low molecular weight heparin (LMWH) may be the optimal prophylaxis in most ICU patients, but there is a lack of sufficient data including the paucity of VTE consensus and guidelines documents pertaining to critically ill patients. CONCLUSIONS: This article reviews background, current options, and recommendations regarding VTE in intensive care population emphasizing special diagnostic and treatment considerations in the ICU setting.

[Challenges in prevention venous thromboembolism: critical ill patient approach]. / Desafios na profilaxia do tromboembolismo venoso: abordagem do paciente crítico.

BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE), with includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication in critically ill patients, resulting in high morbidity and mortality. CONTENTS: Most patients treated in intensive care units (ICU) face a high risk of thromboembolic complications. Despite these considerations, the prevention of VTE may not be as high a priority in ICU patients as it is in other high-risk patient groups. Low molecular weight heparin (LMWH) may be the optimal prophylaxis in most ICU patients, but there is a lack of sufficient data including the paucity of VTE consensus and guidelines documents pertaining to critically ill patients. CONCLUSIONS: This article reviews background, current options, and recommendations regarding VTE in intensive care population emphasizing special diagnostic and treatment considerations in the ICU setting.