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ABSTRACT Objective: COVID-19 has been associated with a significant burden to those who survive the acute phase. We aimed to describe the quality of life and symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) at 90 days after hospital discharge of COVID-19 patients. Methods: Patients with COVID-19 admitted to a private hospital in the city of São Paulo, Brazil, between April of 2020 and April of 2021 were interviewed by telephone at 30 and 90 days after discharge to assess the quality of life and symptoms of depression, anxiety, and PTSD. Results: A total of 2,138 patients were included. The mean age was 58.6 ± 15.8 years, and the median length of hospital stay was 9.0 (5.0-15.8) days. Between the two time points, depression increased from 3.1% to 7.2% (p < 0.001), anxiety increased from 3.2% to 6.2% (p < 0.001), and PTSD increased from 2.3% to 5.0% (p < 0.001). At least one physical symptom related to COVID-19 diagnosis persisted in 32% of patients at day 90. Conclusions: Persistence of physical symptoms was high even at 90 days after discharge. Although the prevalence of symptoms of anxiety, depression, and PTSD was low, these symptoms persisted for three months, with a significant increase between the time points. This finding indicates the need to identify at-risk patients so that they can be given an appropriate referral at discharge.
RESUMO Objetivo: A COVID-19 tem sido associada a um fardo significativo para aqueles que sobrevivem à fase aguda. Nosso objetivo foi descrever a qualidade de vida e sintomas de ansiedade, depressão e transtorno de estresse pós-traumático (TEPT) 90 dias após a alta hospitalar em pacientes com COVID-19. Métodos: Pacientes com COVID-19 internados em um hospital privado na cidade de São Paulo (SP) entre abril de 2020 e abril de 2021 foram entrevistados por telefone 30 e 90 dias após a alta para avaliar a qualidade de vida e sintomas de depressão, ansiedade e TEPT. Resultados: Foram incluídos 2.138 pacientes. A média de idade foi de 58,6 ± 15,8 anos, e a mediana do tempo de internação hospitalar foi de 9,0 (5,0-15,8) dias. Entre os dois momentos, a depressão aumentou de 3,1% para 7,2% (p < 0,001), a ansiedade, de 3,2% para 6,2% (p < 0,001), e o TEPT, de 2,3% para 5,0% (p < 0,001). Pelo menos um sintoma físico relacionado ao diagnóstico de COVID-19 persistia em 32% dos pacientes no 90º dia. Conclusões: A persistência dos sintomas físicos foi elevada mesmo 90 dias após a alta. Embora a prevalência de sintomas de ansiedade, depressão e TEPT tenha sido baixa, esses sintomas persistiram por três meses, com aumento significativo entre os momentos. Esse achado indica a necessidade de identificar os pacientes de risco para que possam receber o encaminhamento adequado no momento da alta.
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Purpose: There is a significant lack of epidemiological data on hereditary cancer in Northeast Brazil. This is the largest study on the prevalence and mutational spectrum of cancer predisposition genes conducted in this region and the first in the State of Ceará. Methods: Patients ≥18 years of age that were referred to CHANCE (Grupo de Câncer Hereditário do Ceará) from March 2014 to December 2020 with testing criteria for breast cancer susceptibility genes according to NCCN v.1.2021 were eligible to participate. The inclusion of patients was limited to one individual per family and to those born in the State of Ceará. All patients underwent a hereditary cancer panel testing with at least 30 genes. Results: A total of 355 patients were included, and 97 (27.3%) carried a P/LP germline variant in 18 different genes. Among the 97 P/LP carriers, BRCA1 (31, 31.9%) and BRCA2 (25, 25.7%) were the most frequently mutated genes, followed by PALB2 (10, 10.3%), CHEK2 (7, 7.2%) and ATM (4, 4.1%). A small number of recurrent variants (detected in three or more individuals) in BRCA1, BRCA2, CHEK2 and ATM represented the majority of the P/LP variants described in this cohort. Conclusion: In this cohort, the prevalence of L/PL was high, particularly involving the BRCA1, BRCA2, PALB2, CHEK2 and ATM genes and, to a lesser extent than expected, the TP53 gene. A high frequency of recurrent variants was also observed, for which further and larger analyses should clarify the presence of any possible founder effect. Characterizing the mutational profile of cancer predisposition genes in diverse populations may contribute to cancer prevention and therapeutic management.
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RESUMO Objetivo: Comparar a mecânica pulmonar e os desfechos entre a síndrome do desconforto respiratório agudo associada à COVID-19 e a síndrome do desconforto respiratório agudo não associada à COVID-19. Métodos: Combinamos dados de dois ensaios randomizados sobre a síndrome do desconforto respiratório agudo, um incluindo apenas pacientes com COVID-19 e o outro incluindo apenas pacientes sem COVID-19, para determinar se a síndrome do desconforto respiratório agudo associada à COVID-19 está associada à maior mortalidade aos 28 dias do que a síndrome do desconforto respiratório agudo não associada à COVID-19 e também examinar as diferenças na mecânica pulmonar entre esses dois tipos de síndrome do desconforto respiratório agudo. Resultados: Foram incluídos na análise principal 299 pacientes com síndrome do desconforto respiratório agudo associada à COVID-19 e 1.010 pacientes com síndrome do desconforto respiratório agudo não associada à COVID-19. Os resultados mostraram que os pacientes sem COVID-19 utilizaram pressão positiva expiratória final mais alta (12,5cmH2O; DP 3,2 versus 11,7cmH2O; DP 2,8; p < 0,001), foram ventilados com volumes correntes mais baixos (5,8mL/kg; DP 1,0 versus 6,5mL/kg; DP 1,2; p < 0,001) e apresentaram menor complacência respiratória estática ajustada para o peso ideal (0,5mL/cmH2O/kg; DP 0,3 versus 0,6mL/cmH2O/kg; DP 0,3; p = 0,01). Não houve diferença entre os grupos quanto à mortalidade aos 28 dias (52,3% versus 58,9%; p = 0,52) ou à duração da ventilação mecânica nos primeiros 28 dias entre os sobreviventes (13 [IQ 5 - 22] dias versus 12 [IQ 6 - 26] dias; p = 0,46). Conclusão: Esta análise mostrou que os pacientes com síndrome do desconforto respiratório agudo não associada à COVID-19 têm mecânica pulmonar diferente, mas desfechos semelhantes aos dos pacientes com síndrome do desconforto respiratório agudo associada à COVID-19. Após pareamento por escore de propensão, não houve diferença na mecânica pulmonar e nem nos desfechos entre os grupos.
ABSTRACT Objective: To compare the lung mechanics and outcomes between COVID-19-associated acute respiratory distress syndrome and non-COVID-19-associated acute respiratory distress syndrome. Methods: We combined data from two randomized trials in acute respiratory distress syndrome, one including only COVID-19 patients and the other including only patients without COVID-19, to determine whether COVID-19-associated acute respiratory distress syndrome is associated with higher 28-day mortality than non-COVID-19 acute respiratory distress syndrome and to examine the differences in lung mechanics between these two types of acute respiratory distress syndrome. Results: A total of 299 patients with COVID-19-associated acute respiratory distress syndrome and 1,010 patients with non-COVID-19-associated acute respiratory distress syndrome were included in the main analysis. The results showed that non-COVID-19 patients used higher positive end-expiratory pressure (12.5cmH2O; SD 3.2 versus 11.7cmH2O SD 2.8; p < 0.001), were ventilated with lower tidal volumes (5.8mL/kg; SD 1.0 versus 6.5mL/kg; SD 1.2; p < 0.001) and had lower static respiratory compliance adjusted for ideal body weight (0.5mL/cmH2O/kg; SD 0.3 versus 0.6mL/cmH2O/kg; SD 0.3; p = 0.01). There was no difference between groups in 28-day mortality (52.3% versus 58.9%; p = 0.52) or mechanical ventilation duration in the first 28 days among survivors (13 [IQR 5 - 22] versus 12 [IQR 6 - 26], p = 0.46). Conclusion: This analysis showed that patients with non-COVID-19-associated acute respiratory distress syndrome have different lung mechanics but similar outcomes to COVID-19-associated acute respiratory distress syndrome patients. After propensity score matching, there was no difference in lung mechanics or outcomes between groups.
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BACKGROUND: Coexistence of cancer and COVID-19 is associated with worse outcomes. However, the studies on cancer-related characteristics associated with worse COVID-19 outcomes have shown controversial results. The objective of the study was to evaluate cancer-related characteristics associated with invasive mechanical ventilation use or in-hospital mortality in patients with COVID-19 admitted to intensive care unit (ICU). METHODS: We designed a cohort multicenter study including adults with active cancer admitted to ICU due to COVID-19. Seven cancer-related characteristics (cancer status, type of cancer, metastasis occurrence, recent chemotherapy, recent immunotherapy, lung tumor, and performance status) were introduced in a multilevel logistic regression model as first-level variables and hospital was introduced as second-level variable (random effect). Confounders were identified using directed acyclic graphs. RESULTS: We included 274 patients. Required to undergo invasive mechanical ventilation were 176 patients (64.2%) and none of the cancer-related characteristics were associated with mechanical ventilation use. Approximately 155 patients died in hospital (56.6%) and poor performance status, measured with the Eastern Cooperative Oncology Group (ECOG) score was associated with increased in-hospital mortality, with odds ratio = 3.54 (1.60-7.88, 95% CI) for ECOG =2 and odds ratio = 3.40 (1.60-7.22, 95% CI) for ECOG = 3 to 4. Cancer status, cancer type, metastatic tumor, lung cancer, and recent chemotherapy or immunotherapy were not associated with in-hospital mortality. CONCLUSIONS: In patients with active cancer and COVID-19 admitted to ICU, poor performance status was associated with in-hospital mortality but not with mechanical ventilation use. Cancer status, cancer type, metastatic tumor, lung cancer, and recent chemotherapy or immunotherapy were not associated with invasive mechanical ventilation use or in-hospital mortality.
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BACKGROUND: Approximately 5% of COVID-19 patients develop respiratory failure and need ventilatory support, yet little is known about the impact of mechanical ventilation strategy in COVID-19. Our objective was to describe baseline characteristics, ventilatory parameters, and outcomes of critically ill patients in the largest referral center for COVID-19 in Sao Paulo, Brazil, during the first surge of the pandemic. METHODS: This cohort included COVID-19 patients admitted to the intensive care units (ICUs) of an academic hospital with 94 ICU beds, a number expanded to 300 during the pandemic as part of a state preparedness plan. Data included demographics, advanced life support therapies, and ventilator parameters. The main outcome was 28-day survival. We used a multivariate Cox model to test the association between protective ventilation and survival, adjusting for PF ratio, pH, compliance, and PEEP. RESULTS: We included 1503 patients from March 30 to June 30, 2020. The mean age was 60 ± 15 years, and 59% were male. During 28-day follow-up, 1180 (79%) patients needed invasive ventilation and 666 (44%) died. For the 984 patients who were receiving mechanical ventilation in the first 24 h of ICU stay, mean tidal volume was 6.5 ± 1.3 mL/kg of ideal body weight, plateau pressure was 24 ± 5 cmH2O, respiratory system compliance was 31.9 (24.4-40.9) mL/cmH2O, and 82% of patients were ventilated with protective ventilation. Noninvasive ventilation was used in 21% of patients, and prone, in 36%. Compliance was associated with survival and did not show a bimodal pattern that would support the presence of two phenotypes. In the multivariable model, protective ventilation (aHR 0.73 [95%CI 0.57-0.94]), adjusted for PF ratio, compliance, PEEP, and arterial pH, was independently associated with survival. CONCLUSIONS: During the peak of the epidemic in Sao Paulo, critically ill patients with COVID-19 often required mechanical ventilation and mortality was high. Our findings revealed an association between mechanical ventilation strategy and mortality, highlighting the importance of protective ventilation for patients with COVID-19.
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RESUMO Objetivo: A infecção causada pelo coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2) disseminou-se por todo o mundo e foi categorizada como pandemia. As manifestações mais comuns da infecção pelo SARS-CoV-2 (doença pelo coronavírus 2019 - COVID-19) se referem a uma pneumonia viral com graus variáveis de comprometimento respiratório e até 40% dos pacientes hospitalizados, que podem desenvolver uma síndrome do desconforto respiratório agudo. Diferentes ensaios clínicos avaliaram o papel dos corticosteroides na síndrome do desconforto respiratório agudo não relacionada com COVID-19, obtendo resultados conflitantes. Delineamos o presente estudo para avaliar a eficácia da administração endovenosa precoce de dexametasona no número de dias vivo e sem ventilação mecânica nos 28 dias após a randomização, em pacientes adultos com quadro moderado ou grave de síndrome do desconforto respiratório agudo causada por COVID-19 provável ou confirmada. Métodos: Este é um ensaio pragmático, prospectivo, randomizado, estratificado, multicêntrico, aberto e controlado que incluirá 350 pacientes com quadro inicial (menos de 48 horas antes da randomização) de síndrome do desconforto respiratório agudo moderada ou grave, definida segundo os critérios de Berlim, causada por COVID-19. Os pacientes elegíveis serão alocados de forma aleatória para tratamento padrão mais dexametasona (Grupo Intervenção) ou tratamento padrão sem dexametasona (Grupo Controle). Os pacientes no Grupo Intervenção receberão dexametasona 20mg por via endovenosa uma vez ao dia, por 5 dias, e, a seguir, dexametasona por via endovenosa 10mg ao dia por mais 5 dias, ou até receber alta da unidade de terapia intensiva, o que ocorrer antes. O desfecho primário será o número de dias livres de ventilação mecânica nos 28 dias após a randomização, definido como o número de dias vivo e livres de ventilação mecânica invasiva. Os desfechos secundários serão a taxa de mortalidade por todas as causas no dia 28, a condição clínica no dia 15 avaliada com utilização de uma escala ordinal de seis níveis, a duração da ventilação mecânica desde a randomização até o dia 28, a avaliação com o Sequential Organ Failure Assessment Score após 48 horas, 72 horas e 7 dias, e o número de dias fora da unidade de terapia intensiva nos 28 dias após a randomização.
Abstract Objective: The infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads worldwide and is considered a pandemic. The most common manifestation of SARS-CoV-2 infection (coronavirus disease 2019 - COVID-19) is viral pneumonia with varying degrees of respiratory compromise and up to 40% of hospitalized patients might develop acute respiratory distress syndrome. Several clinical trials evaluated the role of corticosteroids in non-COVID-19 acute respiratory distress syndrome with conflicting results. We designed a trial to evaluate the effectiveness of early intravenous dexamethasone administration on the number of days alive and free of mechanical ventilation within 28 days after randomization in adult patients with moderate or severe acute respiratory distress syndrome due to confirmed or probable COVID-19. Methods: This is a pragmatic, prospective, randomized, stratified, multicenter, open-label, controlled trial including 350 patients with early-onset (less than 48 hours before randomization) moderate or severe acute respiratory distress syndrome, defined by the Berlin criteria, due to COVID-19. Eligible patients will be randomly allocated to either standard treatment plus dexamethasone (Intervention Group) or standard treatment without dexamethasone (Control Group). Patients in the intervention group will receive dexamethasone 20mg intravenous once daily for 5 days, followed by dexamethasone 10mg IV once daily for additional 5 days or until intensive care unit discharge, whichever occurs first. The primary outcome is ventilator-free days within 28 days after randomization, defined as days alive and free from invasive mechanical ventilation. Secondary outcomes are all-cause mortality rates at day 28, evaluation of the clinical status at day 15 assessed with a 6-level ordinal scale, mechanical ventilation duration from randomization to day 28, Sequential Organ Failure Assessment Score evaluation at 48 hours, 72 hours and 7 days and intensive care unit -free days within 28.
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Humanos , Adulto , Pneumonia Viral/tratamento farmacológico , Síndrome do Desconforto Respiratório do Recém-Nascido/tratamento farmacológico , Dexametasona/administração & dosagem , Infecções por Coronavirus/tratamento farmacológico , Glucocorticoides/administração & dosagem , Pneumonia Viral/fisiopatologia , Respiração Artificial , Síndrome do Desconforto Respiratório do Recém-Nascido/virologia , Fatores de Tempo , Estudos Prospectivos , Infecções por Coronavirus/fisiopatologia , Pandemias , Escores de Disfunção Orgânica , COVID-19 , Unidades de Terapia IntensivaRESUMO
OBJECTIVES: We designed a cohort study to describe characteristics and outcomes of patients with coronavirus disease (COVID-19) admitted to the intensive care unit (ICU) in the largest public hospital in Sao Paulo, Brazil, as Latin America becomes the epicenter of the pandemic. METHODS: This is the protocol for a study being conducted at an academic hospital in Brazil with 300 adult ICU beds dedicated to COVID-19 patients. We will include adult patients admitted to the ICU with suspected or confirmed COVID-19 during the study period. The main outcome is ICU survival at 28 days. Data will be collected prospectively and retrospectively by trained investigators from the hospital's electronic medical records, using an electronic data capture tool. We will collect data on demographics, comorbidities, severity of disease, and laboratorial test results at admission. Information on the need for advanced life support and ventilator parameters will be collected during ICU stay. Patients will be followed up for 28 days in the ICU and 60 days in the hospital. We will plot Kaplan-Meier curves to estimate ICU and hospital survival and perform survival analysis using the Cox proportional hazards model to identify the main risk factors for mortality. ClinicalTrials.gov: NCT04378582. RESULTS: We expect to include a large sample of patients with COVID-19 admitted to the ICU and to be able to provide data on admission characteristics, use of advanced life support, ICU survival at 28 days, and hospital survival at 60 days. CONCLUSIONS: This study will provide epidemiological data about critically ill patients with COVID-19 in Brazil, which could inform health policy and resource allocation in low- and middle-income countries.
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Humanos , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Projetos de Pesquisa , Brasil , Estudos de Coortes , Mortalidade Hospitalar , Estudos Observacionais como Assunto , Pandemias , Betacoronavirus , SARS-CoV-2 , COVID-19 , Hospitais Universitários , Unidades de Terapia IntensivaRESUMO
BACKGROUND AND AIMS: To investigate whether performing alveolar recruitment or adding inspiratory pauses could promote physiologic benefits (VT) during moderately-high-frequency positive pressure ventilation (MHFPPV) delivered by a conventional ventilator in a porcine model of severe acute respiratory distress syndrome (ARDS). METHODS: Prospective experimental laboratory study with eight pigs. Induction of acute lung injury with sequential pulmonary lavages and injurious ventilation was initially performed. Then, animals were ventilated on a conventional mechanical ventilator with a respiratory rate (RR) = 60 breaths/minute and PEEP titrated according to ARDS Network table. The first two steps consisted of a randomized order of inspiratory pauses of 10 and 30% of inspiratory time. In final step, we removed the inspiratory pause and titrated PEEP, after lung recruitment, with the aid of electrical impedance tomography. At each step, PaCO2 was allowed to stabilize between 57-63 mmHg for 30 minutes. RESULTS: The step with RR of 60 after lung recruitment had the highest PEEP when compared with all other steps (17 [16,19] vs 14 [10, 17]cmH2O), but had lower driving pressures (13 [13,11] vs 16 [14, 17]cmH2O), higher P/F ratios (212 [191,243] vs 141 [105, 184] mmHg), lower shunt (23 [20, 23] vs 32 [27, 49]%), lower dead space ventilation (10 [0, 15] vs 30 [20, 37]%), and a more homogeneous alveolar ventilation distribution. There were no detrimental effects in terms of lung mechanics, hemodynamics, or gas exchange. Neither the addition of inspiratory pauses or the alveolar recruitment maneuver followed by decremental PEEP titration resulted in further reductions in VT. CONCLUSIONS: During MHFPPV set with RR of 60 bpm delivered by a conventional ventilator in severe ARDS swine model, neither the inspiratory pauses or PEEP titration after recruitment maneuver allowed reduction of VT significantly, however the last strategy decreased driving pressures and improved both shunt and dead space.
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Modelos Animais de Doenças , Ventilação de Alta Frequência , Lesão Pulmonar/fisiopatologia , Alvéolos Pulmonares/fisiologia , Animais , Masculino , Estudos Prospectivos , SuínosRESUMO
ABSTRACT In patients with severe respiratory failure, either hypoxemic or hypercapnic, life support with mechanical ventilation alone can be insufficient to meet their needs, especially if one tries to avoid ventilator settings that can cause injury to the lungs. In those patients, extracorporeal membrane oxygenation (ECMO), which is also very effective in removing carbon dioxide from the blood, can provide life support, allowing the application of protective lung ventilation. In this review article, we aim to explore some of the most relevant aspects of using ECMO for respiratory support. We discuss the history of respiratory support using ECMO in adults, as well as the clinical evidence; costs; indications; installation of the equipment; ventilator settings; daily care of the patient and the system; common troubleshooting; weaning; and discontinuation.
RESUMO Em pacientes com insuficiência respiratória grave (hipoxêmica ou hipercápnica), o suporte somente com ventilação mecânica pode ser insuficiente para suas necessidades, especialmente quando se tenta evitar o uso de parâmetros ventilatórios que possam causar danos aos pulmões. Nesses pacientes, extracorporeal membrane oxygenation (ECMO, oxigenação extracorpórea por membrana), que também é muito eficaz na remoção de dióxido de carbono do sangue, pode manter a vida, permitindo o uso de ventilação pulmonar protetora. No presente artigo de revisão, objetivamos explorar alguns dos aspectos mais relevantes do suporte respiratório por ECMO. Discutimos a história do suporte respiratório por ECMO em adultos; evidências clínicas; custos; indicações; instalação do equipamento; parâmetros ventilatórios; cuidado diário do paciente e do sistema; solução de problemas comuns; desmame e descontinuação.
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Humanos , Adulto , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório/terapia , Insuficiência Respiratória/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Hipercapnia , Hipóxia , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/fisiopatologia , Insuficiência Respiratória/diagnóstico por imagem , Insuficiência Respiratória/fisiopatologia , Infecções Respiratórias/fisiopatologia , Infecções Respiratórias/terapiaRESUMO
RESUMO Objetivo: Explorar os fatores associados aos níveis sanguíneos da pressão parcial de oxigênio e da pressão parcial de gás carbônico. Métodos: Os fatores associados com a regulação do oxigênio e de gás carbônico foram investigados em um modelo com porcos em apneia com suporte de oxigenação por membrana extracorpórea venovenosa. Foi testada uma sequência predefinida de fluxos de sangue e gás. Resultados: A oxigenação associou-se principalmente com o fluxo da oxigenação por membrana extracorpórea (coeficiente beta = 0,036mmHg/mL/minuto), débito cardíaco (coeficiente beta = -11,970mmHg/L/minuto) e shunt pulmonar (coeficiente beta = -0,232mmHg/%). As mensurações iniciais da pressão parcial de oxigênio e da pressão parcial de gás carbônico também se associaram com oxigenação, com coeficientes beta de 0,160 e 0,442mmHg/mmHg, respectivamente. A pressão parcial de gás carbônico se associou com débito cardíaco (coeficiente beta = 3,578mmHg/L/minuto), fluxo de gás (coeficiente beta = -2,635mmHg/L/minuto), temperatura (coeficiente beta = 4,514mmHg/°C), pH inicial (coeficiente beta = -66,065mmHg/0,01 unidade) e hemoglobina (coeficiente beta = 6,635mmHg/g/dL). Conclusão: Elevações nos fluxos de sangue de gás em um modelo de oxigenação por membrana extracorpórea venovenosa durante apneia resultaram em aumento da pressão parcial de oxigênio e redução da pressão parcial de gás carbônico, respectivamente. Ainda, sem a possibilidade de uma inferência causal, a pressão parcial de oxigênio associou-se negativamente com o shunt pulmonar e o débito cardíaco, e a pressão parcial de gás carbônico teve associação positiva com o débito cardíaco, temperatura central e hemoglobina inicial.
ABSTRACT Objective: The aim of this study was to explore the factors associated with blood oxygen partial pressure and carbon dioxide partial pressure. Methods: The factors associated with oxygen - and carbon dioxide regulation were investigated in an apneic pig model under veno-venous extracorporeal membrane oxygenation support. A predefined sequence of blood and sweep flows was tested. Results: Oxygenation was mainly associated with extracorporeal membrane oxygenation blood flow (beta coefficient = 0.036mmHg/mL/min), cardiac output (beta coefficient = -11.970mmHg/L/min) and pulmonary shunting (beta coefficient = -0.232mmHg/%). Furthermore, the initial oxygen partial pressure and carbon dioxide partial pressure measurements were also associated with oxygenation, with beta coefficients of 0.160 and 0.442mmHg/mmHg, respectively. Carbon dioxide partial pressure was associated with cardiac output (beta coefficient = 3.578mmHg/L/min), sweep gas flow (beta coefficient = -2.635mmHg/L/min), temperature (beta coefficient = 4.514mmHg/ºC), initial pH (beta coefficient = -66.065mmHg/0.01 unit) and hemoglobin (beta coefficient = 6.635mmHg/g/dL). Conclusion: In conclusion, elevations in blood and sweep gas flows in an apneic veno-venous extracorporeal membrane oxygenation model resulted in an increase in oxygen partial pressure and a reduction in carbon dioxide partial pressure 2, respectively. Furthermore, without the possibility of causal inference, oxygen partial pressure was negatively associated with pulmonary shunting and cardiac output, and carbon dioxide partial pressure was positively associated with cardiac output, core temperature and initial hemoglobin.
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Animais , Oxigênio/metabolismo , Dióxido de Carbono/metabolismo , Débito Cardíaco/fisiologia , Oxigenação por Membrana Extracorpórea/métodos , Pressão Parcial , Suínos , Gasometria , Temperatura Corporal/fisiologia , Hemoglobinas/metabolismoRESUMO
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a technique widely used worldwide to improve gas exchange. Changes in ECMO settings affect both oxygen and carbon dioxide. The impact on oxygenation can be followed closely by continuous pulse oximeter. Conversely, carbon dioxide equilibrates much slower and is not usually monitored directly. METHODS: We investigated the time to stabilization of arterial carbon dioxide partial pressure (PaCO2) following step changes in ECMO settings in 5 apnoeic porcine models under veno-venous ECMO support with polymethylpentene membranes. We collected sequential arterial blood gases at a pre-specified interval of 50 min using a sequence of standardized blood and sweep gas flow combinations. RESULTS: Following the changes in ECMO parameters, the kinetics of carbon dioxide was dependent on sweep gas and ECMO blood flow. With a blood flow of 1500 mL/min, PaCO2 takes longer than 50 min to equilibrate following the changes in sweep gas flow. Furthermore, the sweep gas flow from 3.0 to 10.0 L/min did not significantly affect PaCO2. However, with a blood flow of 3500 mL/min, 50 min was enough for PaCO2 to reach the equilibrium and every increment of sweep gas flow (up to 10.0 L/min) resulted in additional reductions of PaCO2. CONCLUSIONS: Fifty minutes was enough to reach the equilibrium of PaCO2 after ECMO initiation or after changes in blood and sweep gas flow with an ECMO blood flow of 3500 ml/min. Longer periods may be necessary with lower ECMO blood flows.
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Humanos , Choque Séptico/complicações , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Esquerda/etiologia , Sepse/complicações , Disfunção Ventricular Direita/diagnóstico , Disfunção Ventricular Direita/fisiopatologia , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
OBJECTIVE: To analyze the correlations of the blood flow/pump rotation ratio and the transmembrane pressure, CO2 and O2 transfer during the extracorporeal respiratory support. METHODS: Five animals were instrumented and submitted to extracorporeal membrane oxygenation in a five-step protocol, including abdominal sepsis and lung injury. RESULTS: This study showed that blood flow/pump rotations ratio variations are dependent on extracorporeal membrane oxygenation blood flow in a positive logarithmic fashion. Blood flow/pump rotation ratio variations are negatively associated with transmembrane pressure (R2 = 0.5 for blood flow = 1500mL/minute and R2 = 0.4 for blood flow = 3500mL/minute, both with p < 0.001) and positively associated with CO2 transfer variations (R2 = 0.2 for sweep gas flow ≤ 6L/minute, p < 0.001, and R2 = 0.1 for sweep gas flow > 6L/minute, p = 0.006), and the blood flow/pump rotation ratio is not associated with O2 transfer variations (R2 = 0.01 for blood flow = 1500mL/minute, p = 0.19, and R2 = - 0.01 for blood flow = 3500 mL/minute, p = 0.46). CONCLUSION: Blood flow/pump rotation ratio variation is negatively associated with transmembrane pressure and positively associated with CO2 transfer in this animal model. According to the clinical situation, a decrease in the blood flow/pump rotation ratio can indicate artificial lung dysfunction without the occurrence of hypoxemia.
Assuntos
Dióxido de Carbono/metabolismo , Oxigenação por Membrana Extracorpórea/métodos , Lesão Pulmonar/terapia , Oxigênio/metabolismo , Animais , Velocidade do Fluxo Sanguíneo/fisiologia , Modelos Animais de Doenças , Feminino , Lesão Pulmonar/fisiopatologia , Testes de Função Respiratória , Sepse/terapia , SuínosRESUMO
RESUMO Objetivo: Analisar as correlações da taxa de fluxo sanguíneo e rotação da bomba com a pressão transmembrana e a transferência de CO2 e O2 durante o suporte respiratório extracorpóreo. Métodos: Cinco animais foram instrumentalizados e submetidos à oxigenação extracorpórea de membrana em um protocolo de cinco fases, as quais incluíam sepse abdominal e lesão pulmonar. Resultados: Este estudo demonstrou que as variações da taxa de fluxo sanguíneo e rotação da bomba dependem, de forma logarítmica positiva, do fluxo sanguíneo na membrana extracorpórea de oxigenação. As variações da taxa de fluxo sanguíneo e rotação da bomba têm associação negativa com a pressão transmembrana (R2 = 0,5 para o fluxo sanguíneo = 1.500mL/minuto e R2 = 0,4 para o fluxo sanguíneo = 3.500mL/minuto, ambos com p < 0,001) e associação positiva com as variações de transferência de CO2 (R2 = 0,2 para o fluxo do gás de varredura ≤ 6L/minuto, p < 0,001, e R2 = 0,1 para o fluxo de gás de varredura > 6L/minuto, p = 0,006). A taxa de fluxo sanguíneo com a rotação da bomba não se associa às variações na transferência de O2 (R2 = 0,01 para o fluxo sanguíneo = 1.500mL/minuto, p = 0,19, e R2 = -0,01 ao fluxo sanguíneo = 3.500mL/minuto, p = 0,46). Conclusão: Neste modelo em animais, a variação da taxa de fluxo sanguíneo e rotação da bomba se associa negativamente com a pressão transmembrana e positivamente com a transferência de CO2. Conforme a situação clínica, uma diminuição na taxa do fluxo sanguíneo e rotação da bomba pode, na ausência de hipoxemia, indicar uma disfunção do pulmão artificial. .
ABSTRACT Objective: To analyze the correlations of the blood flow/pump rotation ratio and the transmembrane pressure, CO2 and O2 transfer during the extracorporeal respiratory support. Methods: Five animals were instrumented and submitted to extracorporeal membrane oxygenation in a five-step protocol, including abdominal sepsis and lung injury. Results: This study showed that blood flow/pump rotations ratio variations are dependent on extracorporeal membrane oxygenation blood flow in a positive logarithmic fashion. Blood flow/pump rotation ratio variations are negatively associated with transmembrane pressure (R2 = 0.5 for blood flow = 1500mL/minute and R2 = 0.4 for blood flow = 3500mL/minute, both with p < 0.001) and positively associated with CO2 transfer variations (R2 = 0.2 for sweep gas flow ≤ 6L/minute, p < 0.001, and R2 = 0.1 for sweep gas flow > 6L/minute, p = 0.006), and the blood flow/pump rotation ratio is not associated with O2 transfer variations (R2 = 0.01 for blood flow = 1500mL/minute, p = 0.19, and R2 = - 0.01 for blood flow = 3500 mL/minute, p = 0.46). Conclusion: Blood flow/pump rotation ratio variation is negatively associated with transmembrane pressure and positively associated with CO2 transfer in this animal model. According to the clinical situation, a decrease in the blood flow/pump rotation ratio can indicate artificial lung dysfunction without the occurrence of hypoxemia. Objetivo: Analisar as correlações da taxa de fluxo sanguíneo e rotação da bomba com a pressão transmembrana e a transferência de CO2 e O2 durante o suporte respiratório extracorpóreo. .
Assuntos
Animais , Feminino , Oxigênio/metabolismo , Dióxido de Carbono/metabolismo , Oxigenação por Membrana Extracorpórea/métodos , Lesão Pulmonar/terapia , Testes de Função Respiratória , Suínos , Velocidade do Fluxo Sanguíneo/fisiologia , Sepse/terapia , Modelos Animais de Doenças , Lesão Pulmonar/fisiopatologiaAssuntos
Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , /genética , Neoplasias da Mama Masculina/genética , Carcinoma Ductal de Mama/genética , Carcinoma Lobular/genética , Carcinoma Papilar/genética , Receptores Androgênicos/genética , Neoplasias da Mama Masculina/complicações , Neoplasias da Mama Masculina/epidemiologia , Carcinoma Ductal de Mama/epidemiologia , Carcinoma Lobular/etnologia , Carcinoma Papilar/epidemiologia , Egito/epidemiologia , Predisposição Genética para Doença , Cirrose Hepática/complicações , Marrocos/epidemiologia , Repetições de Trinucleotídeos/genéticaRESUMO
Objetivo: Analisar o custo-utilidade do uso da oxigenação extracorpórea para pacientes com síndrome da angústia respiratória aguda grave no Brasil. Métodos: Com bancos de dados de estudos previamente publicados, foi construída uma árvore encadeada de decisões. Os custos foram extraídos da média de 3 meses do preço pago pelo Sistema Único de Saúde em 2011. Com 10 milhões de pacientes simulados com desfechos e custos predeterminados, uma análise da relação de incremento de custo e de anos de vida ganhos ajustados pela qualidade (custo-utilidade) foi realizada com sobrevida de 40 e 60% dos pacientes que usaram oxigenação extracorpórea. Resultados: A árvore de decisões resultou em 16 desfechos com técnicas diferentes de suporte à vida. Com a sobrevida de 40/60%, respectivamente, o incremento de custos foi de R$ -301,00/-14,00, com o preço pago de R$ -30.913,00/-1.752,00 por ano de vida ganho ajustado pela qualidade para 6 meses e de R$ -2.386,00/-90,00 por ano de vida ganho ajustado pela qualidade até o fim de vida, quando se analisaram todos os pacientes com síndrome da angústia respiratória aguda grave. Analisando somente os pacientes com hipoxemia grave (relação da pressão parcial de oxigênio no sangue sobre a fração inspirada de oxigênio <100mmHg), o incremento de custos foi de R$ -5.714,00/272,00, com preço por ano de vida ganho ajustado pela qualidade em 6 meses de R$ -9.521,00/293,00, e com o custo de R$ -280,00/7,00 por ano de vida ganho ajustado pela qualidade. Conclusão: A relação de custo-utilidade do uso da oxigenação extracorpórea no Brasil foi potencialmente aceitável neste estudo hipotético. .
Objective: To analyze the cost-utility of using extracorporeal oxygenation for patients with severe acute respiratory distress syndrome in Brazil. Methods: A decision tree was constructed using databases from previously published studies. Costs were taken from the average price paid by the Brazilian Unified Health System (Sistema Único de Saúde; SUS) over three months in 2011. Using the data of 10,000,000 simulated patients with predetermined outcomes and costs, an analysis was performed of the ratio between cost increase and years of life gained, adjusted for quality (cost-utility), with survival rates of 40 and 60% for patients using extracorporeal membrane oxygenation. Results: The decision tree resulted in 16 outcomes with different life support techniques. With survival rates of 40 and 60%, respectively, the increased costs were R$=-301.00/-14.00, with a cost of R$=-30,913.00/-1,752.00 paid per six-month quality-adjusted life-year gained and R$=-2,386.00/-90.00 per quality-adjusted life-year gained until the end of life, when all patients with severe ARDS were analyzed. Analyzing only patients with severe hypoxemia (i.e., a ratio of partial oxygen pressure in the blood to the fraction of inspired oxygen <100mmHg), the increased cost was R$=-5,714.00/272.00, with a cost per six-month quality-adjusted life-year gained of R$=-9,521.00/293.00 and a cost of R$=-280.00/7.00 per quality-adjusted life-year gained. Conclusion: The cost-utility ratio associated with the use of extracorporeal membrane oxygenation in Brazil is potentially acceptable according to this hypothetical study. .
Assuntos
Adulto , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Oxigênio/sangue , Anos de Vida Ajustados por Qualidade de Vida , Síndrome do Desconforto Respiratório/terapia , Brasil , Bases de Dados Factuais , Árvores de Decisões , Oxigenação por Membrana Extracorpórea/economia , Pressão Parcial , Síndrome do Desconforto Respiratório/economia , Síndrome do Desconforto Respiratório/fisiopatologia , Índice de Gravidade de Doença , Taxa de SobrevidaRESUMO
Objective: Discomfort and noncompliance with noninvasive ventilation (NIV) interfaces are obstacles to NIV success. Total face masks (TFMs) are considered to be a very comfortable NIV interface. However, due to their large internal volume and consequent increased CO2 rebreathing, their orifices allow proximal leaks to enhance CO2 elimination. The ventilators used in the ICU might not adequately compensate for such leakage. In this study, we attempted to determine whether ICU ventilators in NIV mode are suitable for use with a leaky TFM. Methods: This was a bench study carried out in a university research laboratory. Eight ICU ventilators equipped with NIV mode and one NIV ventilator were connected to a TFM with major leaks. All were tested at two positive end-expiratory pressure (PEEP) levels and three pressure support levels. The variables analyzed were ventilation trigger, cycling off, total leak, and pressurization. Results: Of the eight ICU ventilators tested, four did not work (autotriggering or inappropriate turning off due to misdetection of disconnection); three worked with some problems (low PEEP or high cycling delay); and one worked properly. Conclusions: The majority of the ICU ventilators tested were not suitable for NIV with a leaky TFM. .
Objetivo: O desconforto e a falta de adaptação às interfaces de ventilação não invasiva (VNI) são obstáculos ao sucesso da VNI. A máscara facial total (MFT) é uma interface de VNI considerada muito confortável. No entanto, devido a seu grande volume interno e, consequentemente, ao aumento da reinalação de CO2, a MFT tem orifícios que permitem vazamentos proximais para melhorar a eliminação de CO2. É possível que os ventiladores usados na UTI não compensem esse vazamento adequadamente. Neste estudo, buscamos determinar se ventiladores de UTI com módulo de VNI podem ser usados com MFT com grandes vazamentos. Métodos: Estudo em simulador mecânico conduzido em um laboratório universitário de pesquisa. Oito ventiladores de UTI equipados para realizar VNI e um ventilador específico para VNI foram conectados a uma MFT com grandes vazamentos. Todos foram testados com dois níveis de positive end-expiratory pressure (PEEP, pressão expiratória final positiva) e três níveis de pressão de suporte. As variáveis analisadas foram disparo do ventilador, ciclagem, vazamento total e pressurização. Resultados: Dos oito ventiladores de UTI, quatro não funcionaram (autodisparo ou desligamento inapropriado por detecção incorreta de desconexão), três funcionaram com alguns problemas (valores baixos de PEEP ou grande atraso na ciclagem do ventilador) e apenas um funcionou adequadamente. Conclusões: A maioria dos ventiladores de UTI testados mostrou-se inadequada para VNI com MFT com grandes vazamentos. .
Assuntos
Humanos , Análise de Falha de Equipamento/normas , Máscaras/normas , Ventilação não Invasiva/instrumentação , Ventiladores Mecânicos/normas , Simulação por Computador , Desenho de Equipamento , Análise de Falha de Equipamento/métodos , Unidades de Terapia Intensiva , Modelos Biológicos , Máscaras/efeitos adversos , Ventilação não Invasiva/efeitos adversos , Ventiladores Mecânicos/efeitos adversosRESUMO
OBJECTIVE: Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution. METHODS: Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output. CONCLUSION: Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions.