Temperature management in acute brain injury: A narrative review.

Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.

Índice biespectral y tasa de supresión tras parada cardiaca: ¿son útiles para individualizar planes de escalada terapéutica? / Bispectral index and suppression ratio after cardiac arrest: are they useful as bedside tools for rational treatment escalation plans?

Introducción y objetivos: La disfunción miocárdica contribuye a la mortalidad precoz (24-72 horas) de los supervivientes de parada cardiaca (PC). Actualmente, la decisión de implantar un dispositivo de soporte circulatorio en este contexto se toma con información limitada acerca del potencial de recuperación neurológica (PRN) del paciente, lo que en muchas ocasiones termina en infratratamiento. Por tanto, requerimos de herramientas accesibles y fiables que añadan información sobre el PRN y ayuden a establecer planes individualizados de escalada terapéutica. Métodos: Se recogieron valores de índice biespectral (BIS) y tasa de supresión (TS) en supervivientes de una PC sometidos a control de la temperatura corporal. La función neurológica se evaluó con la escala Cerebral Performance Category (CPC). Resultados: Se incluyeron 340 pacientes. En la primera evaluación neurológica completa, 211 (62,1%) alcanzaron buen pronóstico (CPC 1-2). Los valores de BIS fueron significativamente mayores y los de TS menores, en pacientes con CPC 1-2. Un BIS promedio> 26 en las primeras 12 horas predijo buena evolución neurológica (sensibilidad 89,5%; especificidad 75,8%; AUC=0,869), mientras que una TS promedio> 24 en las primeras 12 horas predijo mala evolución o CPC 3-5 (sensibilidad 91,5%; especificidad 81,8%; AUC=0,906). Los valores horarios de BIS/TS mostraron buena capacidad predictiva (AUC> 0,85) desde la 2.a hora para TS y 4.a para BIS. Conclusiones: El BIS/TS permiten estimar el PRN tras una PC. Este hallazgo puede contribuir a crear conciencia con respecto a evitar la limitación de escalada terapéutica en pacientes potencialmente recuperables.(AU)

Introduction and objectives: Myocardial dysfunction contributes to early mortality (24-72 hours) among survivors of a cardiac arrest (CA). The benefits of mechanical support in refractory shock should be balanced against the patient's potential for neurological recovery. To date, these early treatment decisions have been taken based on limited information leading mainly to undertreatment. Therefore, there is a need for early, reliable, accessible, and simple tools that offer information on the possibilities of neurological improvement. Methods: We collected data from bispectral index (BIS) and suppression ratio (SR) monitoring of adult comatose survivors of CA managed with targeted temperature management (TTM). Neurological status was assessed according to the Cerebral Performance Category (CPC) scale. Results: We included 340 patients. At the first full neurological evaluation, 211 patients (62.1%) achieved good outcome or CPC 1-2. Mean BIS values were significantly higher and median SR lower in patients with CPC 1-2. An average BIS> 26 during first 12hours of TTM predicted good outcome with 89.5% sensitivity and 75.8% specificity (AUC of 0.869), while average SR values> 24 during the first 12hours of TTM predicted poor outcome (CPC 3-5) with 91.5% sensitivity and 81.8% specificity (AUC, 0.906). Hourly BIS and SR values exhibited good predictive performance (AUC> 0.85), as soon as hour 2 for SR and hour 4 for BIS. Conclusions: BIS/SR are associated with patients’ potential for neurological recovery after CA. This finding could help to create awareness of the possibility of a better outcome in patients who might otherwise be wrongly considered as nonviable and to establish personalized treatment escalation plans.(AU)

Bispectral index and suppression ratio after cardiac arrest: are they useful as bedside tools for rational treatment escalation plans?

INTRODUCTION AND OBJECTIVES: Myocardial dysfunction contributes to early mortality (24-72 hours) among survivors of a cardiac arrest (CA). The benefits of mechanical support in refractory shock should be balanced against the patient's potential for neurological recovery. To date, these early treatment decisions have been taken based on limited information leading mainly to undertreatment. Therefore, there is a need for early, reliable, accessible, and simple tools that offer information on the possibilities of neurological improvement. METHODS: We collected data from bispectral index (BIS) and suppression ratio (SR) monitoring of adult comatose survivors of CA managed with targeted temperature management (TTM). Neurological status was assessed according to the Cerebral Performance Category (CPC) scale. RESULTS: We included 340 patients. At the first full neurological evaluation, 211 patients (62.1%) achieved good outcome or CPC 1-2. Mean BIS values were significantly higher and median SR lower in patients with CPC 1-2. An average BIS> 26 during first 12 hours of TTM predicted good outcome with 89.5% sensitivity and 75.8% specificity (AUC of 0.869), while average SR values> 24 during the first 12 hours of TTM predicted poor outcome (CPC 3-5) with 91.5% sensitivity and 81.8% specificity (AUC, 0.906). Hourly BIS and SR values exhibited good predictive performance (AUC> 0.85), as soon as hour 2 for SR and hour 4 for BIS. CONCLUSIONS: BIS/SR are associated with patients' potential for neurological recovery after CA. This finding could help to create awareness of the possibility of a better outcome in patients who might otherwise be wrongly considered as nonviable and to establish personalized treatment escalation plans.

Nursing care in therapeutic hypothermia in neonates with hypoxic-ischaemic encephalopathy. Review of the literature.

INTRODUCTION: Hypoxic-ischaemic encephalopathy is one of the main causes of neurological damage in the new-born. Therapeutic hypothermia is the current treatment to reduce mortality and disability in new-borns with this condition. OBJECTIVE: To identify nursing care in new-borns with severe to moderate EHI, treated with active therapeutic hypothermia. MATERIALS AND METHODS: A review of the scientific literature was carried out in different databases (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase and Cochrane Plus) over the last five years. The documentary assessment was carried out by peers and the quality was evaluated using the CEBM and GRADE scales. RESULTS: Of the 22 articles selected and reviewed, it is evident that therapeutic hypothermia is effective in reducing the mobility and mortality of neo-nates with hypoxic-ischaemic encephalopathy. Nursing care during hypothermia treatment focuses on four basic pillars: general care for stabilisation of the new-born, preparation of the material, administration of medical treatment in all its phases and emotional support of the family. CONCLUSIONS: Therapeutic hypothermia is effective in reducing the sequelae and mortality of neonates with hypoxic-ischaemic encephalopathy. Nursing care is essential throughout the treatment, in the early detection of complications in the infant and psychological support for parents. It is essential for nurses to receive training in this care.

Prolongación del intervalo QT durante hipotermia terapéutica en un recién nacido con encefalopatía hipóxico isquémica: a propósito de un caso / Prolongation of the QT interval during therapeutic hypothermia in a newborn with hypoxic-ischemic encephalopathy: A case report / Prolongamento do intervalo QT durante hipotermia terapêutica em recém-nascido com encefalopatia hipóxico-isquêmica: relato de caso

Resumen: El síndrome de QT largo adquirido puede ser secundario a la hipotermia, tanto accidental como terapéutica. Es poco el conocimiento sobre el efecto de ésta en la actividad eléctrica cardíaca, sobre todo en recién nacidos, y sus potenciales complicaciones. Se presenta el caso clínico de un recién nacido con diagnóstico de encefalopatía hipóxico isquémica que presenta una prolongación del intervalo QT durante el tratamiento con hipotermia. Se discute la evolución del paciente, que es consistente con lo referido en la literatura sobre el tema: buena evolución, ausencia de arritmias graves o alteraciones hemodinámicas, y normalización del electrocardiograma luego de finalizado el tratamiento.

Summary: Acquired long QT syndrome may be secondary to hypothermia, both accidental and therapeutic. There is not enough knowledge about the effect of hypothermia in cardiac activity and its potential complications, especially in newborns. We present the clinical case of a newborn with a diagnosis of hypoxic ischemic encephalopathy who has a prolonged QT interval during treatment with hypothermia. The evolution of the patient is discussed, which is consistent with what is referred to in the literature on the subject: Good evolution, absence of serious arrhythmias or hemodynamic alterations, and normalization of the ECG after the end of treatment.

Resumo: A síndrome do QT longo adquirida pode ser secundária à hipotermia, tanto acidental quanto terapêutica. Pouco se sabe sobre seu efeito na atividade elétrica cardíaca, principalmente em recém-nascidos, e suas possíveis complicações. Apresentamos o relato de caso clínico de um recém-nascido com diagnóstico de encefalopatia hipóxica isquêmica que apresenta prolongamento do intervalo QT durante o tratamento com hipotermia. Discutimos a evolução do paciente, a que é consistente com a literatura sobre o assunto: boa evolução, ausência de arritmias graves ou alterações hemodinâmicas e normalização do ECG após o término do tratamento.

Cuidados enfermeros a neonatos con encefalopatía hipóxico-isquémica en hipotermia terapéutica. Revisión bibliográfica / Nursing care in therapeutic hypothermia in neonates with hypoxic-ischaemic encephalopathy. Review of the literature

Introducción La encefalopatía hipóxico-isquémica es una de las principales causas de daño neurológico en el neonato. Actualmente, la hipotermia terapéutica es el tratamiento de elección para reducir la mortalidad y la discapacidad en los niños que presentan esta patología. Objetivo Identificar los cuidados enfermeros en recién nacidos con encefalopatía hipóxico-isquémica moderada a severa tratados con hipotermia terapéutica activa. Materiales y métodos Se realizó una revisión de la literatura científica en diferentes bases de datos (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase y Cochrane Plus) durante los últimos 5 años. La valoración documental se realizó por pares y la calidad se evaluó mediante las escalas CEBM y GRADE. Resultados De los 22 artículos seleccionados y revisados se evidencia que la hipotermia terapéutica es efectiva al reducir la morbimortalidad de los neonatos con encefalopatía hipóxico-isquémica. Los cuidados enfermeros durante el tratamiento de hipotermia se centran en 4 pilares básicos: los cuidados generales para la estabilización del recién nacido, la preparación del material, la administración del tratamiento médico en todas sus fases y el soporte emocional de la familia. Conclusiones La hipotermia terapéutica es efectiva al reducir las secuelas y la mortalidad de los neonatos con encefalopatía hipóxico-isquémica. Los cuidados enfermeros son esenciales y están presentes durante todo el tratamiento, detectan precozmente complicaciones en los niños y ofrecen apoyo psicológico a los padres. La formación del personal de enfermería en estos cuidados es fundamental. (AU)

Introduction Hypoxic-ischaemic encephalopathy is one of the main causes of neurological damage in the new-born. Therapeutic hypothermia is the current treatment to reduce mortality and disability in new-borns with this condition. ObjectiveTo identify nursing care in new-borns with severe to moderate hypoxic-ischaemic encephalopathy, treated with active therapeutic hypothermia. Materials and methods A review of the scientific literature was carried out in different databases (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase and Cochrane Plus) over the last five years. The documentary assessment was carried out by peers and the quality was evaluated using the CEBM and GRADE scales. Results Of the 22 articles selected and reviewed, it is evident that therapeutic hypothermia is effective in reducing the mobility and mortality of neo-nates with hypoxic-ischaemic encephalopathy. Nursing care during hypothermia treatment focuses on four basic pillars: general care for stabilisation of the new-born, preparation of the material, administration of medical treatment in all its phases and emotional support of the family. Conclusions Therapeutic hypothermia is effective in reducing the sequelae and mortality of neonates with hypoxic-ischaemic encephalopathy. Nursing care is essential throughout the treatment, in the early detection of complications in the infant and psychological support for parents. It is essential for nurses to receive training in this care. (AU)

Inserción "velamentosa", encefalopatía hipóxico-isquémica y rehabilitación neurológica: reporte de caso / Velamentous cord insertion, ischemic-hypoxic encephalopathy, and neurological rehabilitation: A case report

Resumen. La encefalopatía hipóxico-isquémica es una causa frecuente e importante de daño neurológico en recién nacidos a término y prematuros. Un evento centinela de esta condición es la vasa previa, específicamente cuando existe anormalidad de la placenta como la inserción "velamentosa" del cordón umbilical. Algunos reportes evidencian la asociación entre estas dos condiciones, pero son escasos los que dan cuenta del proceso de recuperación y del pronóstico neurológico de los niños afectados por ellas. Se presenta el caso de un paciente, con antecedentes de inserción "velamentosa" del cordón umbilical y encefalopatía hipóxico-isquémica, que recibió hipotermia terapéutica (cool cap). Se describe su proceso de rehabilitación neurológica y se calculó el porcentaje de probabilidad de presentar esta condición frente a la población sin estos factores. El niño tenía cinco años y el puntaje en su prueba de Apgar fue de 0 al minuto y de 2 a los 15 minutos. Desarrolló encefalopatía hipóxico-isquémica grave secundaria a una inserción "velamentosa" del cordón umbilical sin diagnóstico prenatal, con gran compromiso neurológico y multisistémico inicial. El proceso de recuperación incluyó el manejo inicial multidisciplinario en la unidad de cuidados intensivos neonatales y el inicio temprano de habilitación neurológica. Hoy el niño está escolarizado y en terapia integral, no presenta deficiencias motoras ni sensoriales en el examen físico, aunque la prueba neuropsicológica sugiere un riesgo de trastorno por déficit de atención e hiperactividad. Habitualmente, los niños con encefalopatía hipóxico-isquémica grave presentan discapacidad por deficiencias motoras, cognitivas o conductuales. El haber recibido hipotermia terapéutica y un manejo estructurado de rehabilitación redujo en gran medida las deficiencias esperadas y ha promovido un satisfactorio desarrollo físico y neurológico.

Abstract. Hypoxic-ischemic encephalopathy is a frequent and important cause of neurological problems in term and preterm newborns. A sentinel event of this entity is the vasa previa, specifically when there is an abnormality of the placenta such as a velamentous cord insertion. Some reports have shown the association between these two entities, but those regarding the recovery process and the neurological prognosis of children with both conditions are scarce. We present the case of a patient with a history of velamentous cord insertion and hypoxic-ischemic encephalopathy who received therapeutic hypothermia (cool cap). We describe his neurological rehabilitation process and we calculated the percentage of probability of presenting this condition compared to the population without these factors. The patient was a five-year-old boy with an Apgar index at birth equal to zero at one minute and equal to two at fifteen minutes who developed severe hypoxic-ischemic encephalopathy secondary to a velamentous cord insertion without prenatal diagnosis and a marked initial neurological and multisystemic compromise. The recovery process included early multidisciplinary management in the neonatal intensive care unit and a focus on early neurological habilitation. The patient is currently in school and he undergoes comprehensive therapies; on physical examination, he presents no motor or sensory deficiencies. His neuropsychological test suggests the risk of attention deficit hyperactivity disorder. Children with severe hypoxic-ischemic encephalopathy usually have disabilities due to motor, cognitive, and/or behavioral deficiencies. Having received therapeutic hypothermia and a structured rehabilitation process greatly reduced the expected deficiencies according to prognosis and have promoted satisfactory physical and neurological development.

Nursing care in therapeutic hypothermia in neonates with hypoxic-ischaemic encephalopathy. Review of the literature. / Cuidados enfermeros a neonatos con encefalopatía hipóxico-isquémica en hipotermia terapéutica. Revisión bibliográfica.

INTRODUCTION: Hypoxic-ischaemic encephalopathy is one of the main causes of neurological damage in the new-born. Therapeutic hypothermia is the current treatment to reduce mortality and disability in new-borns with this condition. OBJECTIVE: To identify nursing care in new-borns with severe to moderate hypoxic-ischaemic encephalopathy, treated with active therapeutic hypothermia. MATERIALS AND METHODS: A review of the scientific literature was carried out in different databases (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase and Cochrane Plus) over the last five years. The documentary assessment was carried out by peers and the quality was evaluated using the CEBM and GRADE scales. RESULTS: Of the 22 articles selected and reviewed, it is evident that therapeutic hypothermia is effective in reducing the mobility and mortality of neo-nates with hypoxic-ischaemic encephalopathy. Nursing care during hypothermia treatment focuses on four basic pillars: general care for stabilisation of the new-born, preparation of the material, administration of medical treatment in all its phases and emotional support of the family. CONCLUSIONS: Therapeutic hypothermia is effective in reducing the sequelae and mortality of neonates with hypoxic-ischaemic encephalopathy. Nursing care is essential throughout the treatment, in the early detection of complications in the infant and psychological support for parents. It is essential for nurses to receive training in this care.

Hipotermia terapêutica na encefalopatia hipóxico-isquêmica neonatal: revisão integrativa / Therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy: integrative review / Hipotermia terapéutica em la encefalopatía hipóxico-isquémica neonatal: revisión integrativa

Objetivo: identificar evidências acerca do uso seguro da hipotermia terapêutica em recém-nascidos. Método: revisão integrativa realizada entre junho e julho de 2018, em fontes eletrônicas da Biblioteca Virtual de Saúde e PubMed, por meio da pergunta:"Que evidências podem subsidiar o cuidado de enfermagem voltado para a redução de sequelas em recém-nascidos submetidos à hipotermia terapêutica?".Foram eleitos nove artigos para análise, sendo oito internacionais e um nacional. Resultados:o resfriamento deve acontecer por 72 horas, com hipotermia leve. As indicações para inclusão no protocolo foram: primeiras seis horas de vida, idade gestacional maior que 35 semanas e acidose na primeira hora de vida.São cuidados essenciais: monitoração hemodinâmica, observação da pele, controle térmico retal, vigilância do Eletroencefalograma de Amplitude Integrada. Conclusão: a terapêutica apresenta benefícios, porém sua aplicação depende de protocolo institucional e treinamento das equipes com foco nas potenciais complicações.

Objective: to identify the evidence on safe use of therapeutic hypothermia in newborns. Method: integrative review of the literature, conducted between June and July of 2018, in electronic sources from the Virtual Health Library and PubMed, through the question: "What evidence can support nursing care aimed at reducing sequelae in newborns undergoing therapeutic hypothermia?". Analysis was conducted for nine selected article, being eight from international literature and one from Brazilian national literature. Results: cooling should occur for 72 hours with mild hypothermia. Indications for inclusion in the protocol were: first six hours of life, gestational age greater than 35 weeks and acidosis in the first hour of life. Essential care includes hemodynamic monitoring, skin observation, rectal thermal control, Integrated Amplitude Electroencephalogram surveillance. Conclusion: the therapy has benefits, but its application depends on institutional protocol and team training focusing on potential complications.

Objetivo: identificar la evidencia sobre el uso seguro de la hipotermia terapéutica en recién nacidos. Método: revisión integradora de la literatura, realizada entre junio y julio de 2018, en fuentes electrónicas de la Biblioteca Virtual de Salud y PubMed, a través de la pregunta: "¿Qué evidencia puede apoyar la atención de enfermería dirigida a reducir las secuelas en los recién nacidos que sufren hipotermia terapéutica?". Se realizaron análisis para nueve artículos seleccionados, ocho de literatura internacional y uno de literatura nacional brasileña. Resultados: el enfriamiento debe ocurrir durante 72 horas con hipotermia leve. Las indicaciones para la inclusión en el protocolo fueron: primeras seis horas de vida, edad gestacional mayor de 35 semanas y acidosis en la primera hora de vida. El cuidado esencial incluye monitoreo hemodinámico, observación de la piel, control térmico rectal, vigilancia integrada de electroencefalograma de amplitud. Conclusión: la terapia tiene beneficios, pero su aplicación depende del protocolo institucional y del entrenamiento del equipo, enfocándose en posibles complicaciones.

Change in neuron specific enolase levels in out-of-hospital cardiopulmonary arrest survivors as a simple and useful tool to predict neurological prognosis.

INTRODUCTION AND OBJECTIVES: Neuron-specific enolase (NSE) is a prognostic marker in out-of-hospital cardiopulmonary arrest (OHCA) survivors treated with mild therapeutic hypothermia (MTH). The objectives were to analyze the correlation between dynamic changes in NSE and outcomes and to determine the measurement timing that best predicts neurological status. METHODS: Multicenter cohort study including patients admitted after shockable rhythm OHCA and treated with MTH. Serum NSE was sampled at 2 different times and Δ-NSE (%) was calculated as 100 x (NSE2-NSE1)/NSE1. In-hospital mortality and neurological outcome, as assessed by the Cerebral Performance Category (CPC) scale, were evaluated during admission and after a 6-month follow-up. RESULTS: We included 166 patients admitted to 4 hospitals. In-hospital mortality was 31.9%. Almost 60% of patients had a good neurological recovery (CPC 1-2). On univariate and multivariate logistic regression analyses, an increase in NSE levels was associated with higher in-hospital mortality and worse CPC on discharge and after 6-months (P<.001). Positive Δ-NSE showed an OR=9.28 (95% CI 4.40-19.57) for mortality, OR=11.23 (95% CI 5.24-24.11) for CPC 3-5 at discharge and OR=11.14 (95% CI 5.05-24.55) for CPC 3-5 after 6-months' follow-up (P<.001). The first NSE measurement, conducted at 18 to 24hours, and the second measurement at 69 to 77hours after OHCA showed a high area under the curve in predicting CPC at discharge (0.9389 and 0.9909, respectively; 0.8096 for the whole cohort). CONCLUSIONS: Dynamic changes in NSE serum levels are good markers of hard clinical outcomes after an OHCA due to shockable rhythm in an MTH-treated cohort. NSE measurements at specific intervals after OHCA may predict events even more precisely.

Conocimientos y actitudes sobre encefalopatía hipóxico-isquémica e hipotermia terapéutica: Resultados de una intervención educativa / Knowledge and attitudes on hypoxic-ischemic encephalopathy and therapeutic hypothermia: Results of an educational intervention

Antecedentes: La asixia perinatal, producida al feto/neonato por hipoxia y/o hipoperfusión tisular, puede llevar a ence-falopatía hipóxico-isquémica (EHI). La hipotermia terapéutica (HT) es eicaz para tratar EHI moderada/severa. Objetivo: Determinar conocimientos y actitudes sobre EHI e HT del personal sanitario y estudiantes antes y después de una intervención educativa, Departamento de Pediatría, Hospital Escuela (HE), Tegucigalpa, 2019. Métodos: Estudio cuasi experimental. Médicos, enfermeras, estudiantes de grado y posgrado fueron invitados a participar mediante consentimiento informado. El ensayo consistió en evaluación pre-intervención (Fase 1), seguida de intervención educativa, video y documento enviados por aplicación WhatsApp, y evaluación post-intervención (Fase 2). Se registraron características sociodemográicas. Se evaluó conocimientos (Excelente, Muy bueno, Bue-no, Deiciente) y actitudes (Buena, Regular, Mala, Muy mala). Se midió el cambio (Delta Porcentaje) entre proporción de participantes de acuerdo a conocimientos y actitudes pre y post-intervención. Resultados: De 181 potenciales participantes, en Fase 1 participaron 147 (81.2%) y en Fase 2, 127 (70.2%). Inicialmente, 93.2% (137) demostró un conocimiento deiciente y actitud buena 38.0% (56), regular 28.0% (41), mala 32.0% (47). El conocimiento bueno aumentó en 561.2% (3.1% versus 20.5%), conocimiento muy bueno aumentó en 185.1% (4.7% versus 13.4%), conocimiento deiciente disminuyó en 35.9% (92.2% versus 59.1%). La actitud regular au-mentó en 37.0% (27.0% versus 37.0%), actitud mala disminuyó 30.4% (32.8% versus 22.8%). Discusión: La intervención educativa mejoró conocimiento y actitud en relación a HT y EHI. La HT disponible en HE puede mejorar el desenlace de EHI. Se recomienda fortalecer las medidas educativas institucionales sobre el protocolo de HT...(AU)

Falso aneurisma del sitio de canulación aórtico después de cirugía cardíaca: Informe de un caso y revisión de la literatura / False aneurysm of ascending aortic cannulation site after cardiac surgery. Case report and literature review

RESUMEN El pseudoaneurisma de aorta ascendente, como complicación en cirugía cardíaca, tiene una incidencia menor del 0,5%, pero una mortalidad que varía del 6,7 al 60%. La manipulación aórtica y la infección son los principales factores predisponentes. Su clínica puede ser variada y constituir un hallazgo casual en controles posteriores. Se presenta el caso de una paciente operada de cirugía valvular mitral que a los 11 meses del postoperatorio se le diagnostica un pseudoaneurisma de aorta ascendente, que requirió tratamiento quirúrgico de emergencia. La cirugía fue llevada a cabo con la utilización de canulación periférica extramediastínica, sin requerir parada circulatoria, ni hipotermia para su correcta disección. El caso muestra una variante técnica para enfrentar una enfermedad poco frecuente, pero altamente desafiante, por la necesidad de reintervención y una correcta estrategia quirúrgica.

ABSTRACT False ascending aortic aneurysm, as a complication in cardiac surgery, has an incidence of less than 0.5%, but a mortality that ranges from 6.7% to 60%. Aortic manipulation and infection are the main predisposing factors. Its clinical presentation is non-specific and may be found incidentally on subsequent check-ups. The case of a patient undergoing mitral valve surgery who was diagnosed with ascending aortic false aneurysm, eleven months after postoperative period, requiring emergency surgical treatment is presented. The surgery was performed using extra-mediastinal peripheral cannulation, without induced circulatory arrest or hypothermia for proper dissection. The case shows a technical version to face an uncommon but highly challenging disease as it needs re-interventions and successful surgical strategies.

Hypothermia post-cardiopulmonary resuscitation with low inputs: an experience report / Hipotermia post-ressuscitación cardiopulmonar con bajos insumos: relato de experiencia / Hipotermia pós ressuscitação cardiopulmonar com baixos insumos: relato de experiência

ABSTRACT Objective: to report the experience of conducting directed temperature control of a post-cardiopulmonary resuscitation patient, with reduced and basic inputs available at the institution. Method: an experience report of directed temperature control in patient (age 15 years), after four hours of cardiopulmonary resuscitation in an Intensive Care Unit of a hospital in São Paulo State countryside in 2016, according to the protocol suggested by the American Heart Association, in 2015. There were applications of cold compresses, plastic bags with crushed ice and rectal temperature control. Results: after eight hours, temperature had reached 93.2 ºF. Body cooling was maintained for 24 hours. However, bags with crushed ice were used in the first 6 hours. Conclusion: conduct of nurses to obtain the body cooling with reduced and basic inputs was effective during the stay at the Intensive Care Unit.

RESUMEN Objetivo: relatar la experiencia de la conducción de control dirigido de la temperatura de una paciente después de la resucitación cardiopulmonar, con insumos reducidos y básicos disponibles en la institución. Método: el informe de experiencia de control direccionado de la temperatura en paciente (edad 15 años), después de cuatro horas de resucitación cardiopulmonar en una Unidad de Terapia Intensiva de un hospital del interior del estado de São Paulo, en el año 2016, conforme protocolo sugerido por la American Heart Association en 2015. Se utilizaron aplicaciones de compresas embebidas en agua helada, bolsas plásticas con hielo triturado y control de la temperatura rectal. Resultados: en ocho horas, la temperatura alcanzó los 34 ºC. El enfriamiento corporal se mantuvo durante 24 horas, sin embargo, las bolsas con hielo triturado se utilizaron en las primeras 6 horas. Conclusión: la conducta de los enfermeros para obtener el enfriamiento corporal con insumos reducidos y básicos, se mostró efectiva durante la permanencia en la Unidad de Terapia Intensiva.

RESUMO Objetivo: relatar a experiência da condução de controle direcionado da temperatura de uma paciente pós ressuscitação cardiopulmonar, com insumos reduzidos e básicos disponíveis na instituição. Método: relato de experiência de controle direcionado da temperatura em paciente (idade 15 anos) após quatro horas de ressuscitação cardiopulmonar em uma unidade de terapia intensiva de um hospital do interior do Estado de São Paulo, no ano de 2016, conforme protocolo sugerido pela American Heart Association 2015. Utilizou-se aplicações de compressas embebidas em água gelada, sacos plásticos com gelo triturado e controle da temperatura retal. Resultados: em oito horas a temperatura atingiu 34ºC. O resfriamento corporal foi mantido por 24 horas, todavia os sacos com gelo triturado foram utilizados nas primeiras 6 horas. Conclusão: a conduta dos enfermeiros para obter o resfriamento corporal com insumos reduzidos e básicos, mostrou-se efetiva durante a permanência na unidade de terapia intensiva.

Hipotermia terapéutica controlada. Experiencia en un Hospital de Tercer Nivel / Therapeutic hypothermia. Experience in a Third Level Hospital / Hipotermia terapêutica controlada experiência em um hospital de alta complexidade

Resumen: Objetivo: Presentar la experiencia relacionada a hipotermia terapéutica controlada en pacientes graves que presentaron lesión neurológica aguda. Material y métodos: Estudio clínico, retrospectivo, observacional y descriptivo, en el Departamento de Medicina Crítica de Adultos de un Hospital de Tercer Nivel en un periodo comprendido del 01 de enero de 2016 al 31 de julio de 2017. Pacientes llevados a hipotermia terapéutica. Resultados: Cinco pacientes incluidos en el estudio, con una media de edad de 52.4 años, 80% con padecimientos neurocríticos. El promedio de estancia en la UCI fue de 15.2 días, y de hospitalización 63 días. La media de días de ventilación mecánica fue de 13.8 días. Sesenta porciento de los pacientes desarrolló neumonía asociada a la ventilación mecánica. Cuarenta porciento de los pacientes presentó una discapacidad grave. Conclusiones: La hipotermia terapéutica en el grupo estudiado no impactó de manera positiva en los desenlaces neurológicos. La complicación más frecuente fue la neumonía asociada a la ventilación mecánica.

Abstract: Objective: To present the experience related to controlled therapeutic hypothermia in severe patients who presented acute neurological injury. Material and methods: Clinical, retrospective, observational and descriptive study in the Department of Critical Care of Adults of a Hospital of Third Level in a period between January 1, 2016 and July 31, 2017. Patients taken to therapeutic hypothermia. Results: Five patients included in the study, with a mean age of 52.4 years, 80% with neurocritical conditions. The average stay in the ICU was 15.2 days, and hospitalization was 63 days. The mean number of days of mechanical ventilation was 13.8 days. Sixty percent of patients developed ventilator-associated pneumonia. Forty percent of the patients had a severe disability. Conclusions: Therapeutic hypothermia in the study group did not positively impact neurological outcomes. The most frequent complication was ventilator-associated pneumonia.

Resumo: Objetivo: Apresentar a experiência relacionada à hipotermia terapêutica controlada em pacientes graves que apresentaram lesão neurológica aguda. Material e métodos: Estudo clínico, retrospectivo, observacional e descritivo, no Departamento de Medicina Crítica de adultos, no período de 1 de janeiro de 2016 a 31 de julho de 2017. Pacientes submetidos à Hipotermia Terapêutica. Resultados: Foram incluídos no estudo 5 pacientes com idade média de 52.4 anos, 80% com alterações neurológicas. A permanência média na UTI foi de 15.2 dias e de hospitalização 63 dias. A média de dias de ventilação mecânica foi de 13.8. 60% dos pacientes desenvolveram pneumonia associada à ventilação mecânica. 40% dos pacientes tinham um incapacidade grave. Conclusões: A hipotermia terapêutica no grupo estudado não teve impacto positivo nos desfechos neurológicos. A complicação mais frequente foi pneumonia associada à ventilação mecânica.

Neuroprotección en pacientes con asfixia perinatal / Neuroprotection in patients with perinatal asphyxia

Introducción: la asfixia perinatal (APN) y su consecuencia, la encefalopatía hipóxico isquémica (EHI), son responsables de la elevada morbimortalidad neonatal e infantil. El desarrollo de una estrategia integral de neuroprotección que incluya hipotermia terapéutica busca mitigar sus efectos. Objetivo: evaluar la implementación de un protocolo global de neuroprotección en un servicio de recién nacidos. Metodología: estudio monocéntrico, retrospectivo y observacional de una cohorte de pacientes que recibieron hipotermia controlada entre 2011 y 2014 internados en el Centro Hospitalario Pereira Rossell (CHPR). El protocolo incluyó la formación del personal de enfermería y el equipo médico así como la adecuación tecnológica a tales efectos. Resultados: 20 pacientes cumplieron con criterios de inclusión, 2/20 no completaron las 72 horas necesarias de enfriamiento por alteración de la coagulación y sangrado activo refractario y 4/20 fallecieron. El enfriamiento activo se inició con una mediana de 60 minutos, y el objetivo de 33,5°C se alcanzó con una mediana de 2 horas. Se observó hiperoxia e hipocapnia en la asistencia inicial y acidosis metabólica, hiponatremia e hiperglicemia durante el período de mantenimiento así como sobre-diagnóstico de crisis convulsivas. Los trastornos de la coagulación fueron los efectos adversos más graves. Conclusión: la implementación de un protocolo de asistencia del paciente asfíctico con EHI moderada-severa permite la introducción de hipotermia controlada como estrategia para reducir la mortalidad, colocándola en los niveles observados para los países de altos ingresos. Muestra la necesidad de mejorar la asistencia inicial, de controlar alteraciones del metabolismo ácido-base, metabolismo glucídico, del sodio y sobre todo de las alteraciones de la coagulación como los fenómenos asociados de mayor gravedad.

Introduction: perinatal asphyxia and its consequence, the hypoxic-ischemic encephalopathy are responsible for the high level of morbidity (and mortality) in neonates and children. The development of a comprehensive neuroprotective strategy that includes therapeutic hypothermia, aims to mitigate its effects. Objective: our goal is to achieve the implementation of a global neuroprotection protocol in a newborn service. Methodology: monocentric, retrospective and observational study of a cohort of patients that received controlled hypothermia between 2011 and 2014 and were hospitalized in the Pereira Rossell Hospital Center (CHPR). The protocol included the training of the nursing staff and the medical team as well as the necessary technological adaptation. Results: 20 patients matched the inclusion criteria, 2/20 did not fulfill the 72 hours needed for the cooling by alteration of the coagulation and active refractory bleeding and 4/20 died. The active cooling started with a mean of 60 minutes, and the goal of 33,5°C was reached with a mean of 2 hours. Both hyperoxia and hypocapnia were observed in the initial assistance and metabolic acidosis, hyponatremia and hyperglicemia were also observed during the maintenance period, as well as over-diagnosis of convulsive crisis. Coagulation disorders were the most severe side effects. Conclusion: the implementation of a protocol of assistance of the asphyctic newborn with mild-severe HIE allows the introduction of controlled hypothermia as a strategy to reduce mortality, placing it on the levels observed in higher-income countries. It shows the need of improving the initial assistance, of controlling alterations in the acid-base metabolism, glucidic metabolism, sodium metabolism and above all, of the alterations of the coagulation as the associated phenomena of greatest severity.

[Corrected QT interval during therapeutic hypothermia in hypoxic ischaemic encephalopathy]. / El intervalo QT corregido durante la hipotermia terapéutica en la encefalopatía hipóxico-isquémica.

INTRODUCTION: Therapeutic hypothermia is the standard treatment for hypoxic ischaemic encephalopathy (HIE), despite not knowing all its effects and complications. Sinus bradycardia is one of the consequences of cooling that has been previously documented in the literature, but little is known about the cardiac electrical activity in these patients. OBJECTIVE: To determine the corrected QT (QTc) interval in newborns treated with therapeutic hypothermia for HIE. MATERIAL AND METHODS: A prospective observational study was conducted in all patients treated with hypothermia for HIE that were admitted to our Unit between November 2012 and October 2013. ECGs were performed during hypothermia (every 24h), during the re-warming period (at 34.5°C, 35.5°C, 36.5°C), and on the 7th day of life. RESULTS: A total of 19 patients were included. A prolonged QTc was observed in all patients during hypothermia, and 84% (n=16) had prolonged QTc in all the ECGs during treatment. In 3 patients, one of the ECGs did not have a prolonged QTc. After re-warming, the QTc interval returned to normal in all patients. No statistically significant differences were seen when the degree of HIE (P=.192) or the use of inotropic support (P=.669) were considered. CONCLUSIONS: Therapeutic hypothermia applied to asphyxiated newborns with HIE seems to induce a QTc prolongation that resolves when the patient regains physiological temperature.

Necrosis grasa subcutánea con hipercalcemia persistente en un neonato tratado con hipotermia terapéutica: Reporte de un caso / Subcutaneous fat necrosis and persistent hypercalcaemia in a newborn treated with therapeutic neonatal hypothermia: A case report

La hipotermia terapéutica constituye el tratamiento de elección para los recién nacidos con encefalopatía hipóxico-isquémica moderada-grave, que cambia el pronóstico de estos niños y se acepta como una técnica segura y con escasas complicaciones secundarias considerando su beneficio. Un posible efecto adverso es la necrosis grasa subcutánea, una paniculitis transitoria aguda de presentación durante las primeras semanas de vida. Se presenta un caso de un recién nacido a término afecto de encefalopatía hipóxico-isquémica con lesiones cutáneas en forma de eritema multiforme generalizado y placas eritematosas firmes e induradas en la espalda, los glúteos y las extremidades a los 12 días de vida, tras el tratamiento con hipotermia. El estudio histopatológico, tras la biopsia cutánea, confirmó la sospecha de necrosis grasa subcutánea. Al mes de vida, presentó cifras elevadas de calcio sérico, que precisaron tratamiento con hidratación intravenosa y diuréticos. La calcemia descendió hasta normalizarse a los 3 meses, con desaparición progresiva de las lesiones cutáneas.

Therapeutic hypothermia is the current standard treatment in newborns with moderate to severe hypoxic-ischemic encephalopathy, changing the outcome of these children. It is considered a safe technique with almost no side effects. A possible adverse side event is subcutaneous fat necrosis, which is an acute self-limiting panniculitis that develops during the first weeks of life. We report a case of a newborn at term suffering hypoxic-ischemic encephalopathy with a generalized multiform erythematous rash and firm and indurated plaques over the back, buttocks and extremities on his 12th day of life after being treated with therapeutic hypothermia. Histopathological study after skin punchbiopsy confirmed the suspicion of subcutaneous fat necrosis. The infant developed asymptomatic moderate hypercalcaemia within the first month of life, which was treated with intravenous fluids and diuretics. Serum calcium levels decreased and normalized in 3 months, with progressive disappearance of skin lesions.

ANÁLISE DO DESEMPENHO FÍSICO E DO EQUILÍBRIO SOB INFLUÊNCIA DA CRIOTERAPIA EM ATLETAS DE FUTSAL / PHYSICAL PERFORMANCE AND BALANCE ANALYSIS UNDER INFLUENCE OF CRYOTHERAPY IN INDOOR SOCCER ATHLETES / ANÁLISIS DEL DESEMPEÑO FÍSICO Y EQUILÍBRIO SOB INFLUENCIA DE CRIOTERAPIA EN JUGADORES DE FÚTBOL SALA

Introdução Crioterapia é a aplicação de modalidades de frio com temperatura de 0ºC a 18,3ºC, podendo interferir no desempenho físico e equilíbrio, dependendo da capacidade do indivíduo em manter a estabilização, direcionar padrões de movimentos, controlar a postura e posição articular. Objetivo Avaliar o desempenho físico, a frequência cardíaca e o equilíbrio estático com olhos abertos, em atletas de futsal (futebol de salão), antes e depois da crioimersão nos membros inferiores. Métodos Trinta e dois indivíduos do gênero masculino participaram do estudo, distribuídos aleatoriamente em dois grupos: (A) grupo controle, imersão em água a 24°C por 10 min; (B) grupo intervenção, crioimersão em água com gelo a 10°C por 10 min. Os voluntários realizavam a avaliação do equilíbrio no baropodômetro, em seguida corriam em linha reta e em ziguezague por 100 m, entravam na crioimersão, terminando com uma nova avaliação. Foram analisados o desempenho físico, através dos tempos das corridas, a frequência cardíaca, por meio de um frequencímetro e o equilíbrio, através da baropodometria e estabilometria em apoio bipodal de olhos abertos. Resultados O desempenho físico foi alterado após a crioimersão quando das análises intra e intergrupos. A frequência cardíaca apresentou diferença ao comparar-se antes e após a crio, porém sem diferenças em comparação ao controle. O equilíbrio não foi alterado após a crioimersão e nem em comparação com o grupo controle. Conclusão A crioimersão prejudicou o desempenho físico, quando a atividade foi imediatamente após a mesma, sendo desta forma o gelo não aconselhável quando se deseja desempenho na atividade desportiva. Porém não apresentou interferência na frequência cardíaca e no equilíbrio de atletas de futsal, que podem não ter sido alterados devido ao tempo da crioimersão.

Introduction Cryotherapy is the application of methods of cold temperature of 0°C to 18.3°C, which may interfere in physical performance and balance, depending on the individual's capacity of maintaining stabilization, targeting movement patterns, controlling posture and joint position. Objective To evaluate physical performance, heart rate and static balance with eyes open, in indoor soccer players before and after cold-water immersion of lower limbs. Methods Thirty-two male subjects participated in the study, being randomly divided into two groups: (A) control group, immersion in water at 24°C for 10 minutes, (B) intervention group, immersion in cold-water at 10°C for 10 minutes. The volunteers performed evaluation of balance through a baropodometer, then they ran straight and in zigzag for 100 meters, entered in cold-water immersion, ending with a new assessment. We analyzed physical performance throughout the time of race, the heart rate by means of a frequency counter, and balance through a baropodometer and stabilometry in bipedal support with their eyes open. Results The physical performance was modified after immersion in cold-water in intragroup and intergroup analysis. The heart rate showed difference when comparing before and after cryotherapy, but no differences compared to control. The balance showed no alteration after cryotherapy nor in comparison with the control group. Conclusion Cryotherapy impaired physical performance when the activity was performed immediately thereafter, therefore ice is not recommended when you want performance in sporting activities. Nevertheless, ice had no interference on heart rate and balance of indoor soccer players, which may not have been altered due to the time of immersion.

Introducción Crioterapia es la aplicación de diferentes modalidades de frio con temperatura de 0ºC a 18,3ºC, pudiendo interferir en el rendimiento físico y en el equilibrio, dependiendo de la capacidad del individuo de mantener la estabilización, direccionar padrones de movimientos, controlar la postura y posición articular. Objetivo Evaluar el rendimiento físico, la frecuencia cardíaca y el equilibrio estático con ojos abiertos, en jugadores de fútbol sala, antes y después de crioinmersión en los miembros inferiores. Métodos Treinta y dos individuos del género masculino participaron del estudio, distribuidos aleatoriamente en dos grupos: (A) grupo control, inmersión en agua a 24°C por 10 minutos; (B) grupo intervención, crioinmersión en agua con hielo a 10°C durante 10 minutos. Los voluntarios realizaban la evaluación del equilibrio en un baropodómetro, luego corrían en línea recta y en zigzag durante 100 metros, entraban en la crioinmersión, finalizando con una nueva evaluación. El rendimiento físico fue analizado a través de los tempos de carreras, la frecuencia cardíaca, por medio de un frecuencímetro cardiaco, y el equilibrio a través de baropodometría y estabilometría en apoyo bipodal con ojos abiertos. Resultados El rendimiento físico fue modificado después de la crioinmersión, tanto cuando analizados intra como intergrupal. La frecuencia cardíaca presentó diferencia significativa al comparar-se antes e después de la crioterapia, pero sin diferencias en comparación al control. El equilibrio no fue alterado después de la crioterapia ni en comparación con el grupo control. Conclusión La crioinmersión afectó negativamente el rendimiento físico, cuando la actividad fue realizada inmediatamente después de la misma, siendo de esta manera la crioinmersión no aconsejable cuando se desea incrementar el rendimiento en la actividad deportiva. Pero no presentó interferencia en la frecuencia cardíaca ni en el equilibrio en jugadores de fútbol sala, que pueden no haber sido alterados debido al tempo da crioinmersión.

[Evaluation of nurse workload in patients undergoing therapeutic hypothermia]. / Valoración de la carga de trabajo de Enfermería en pacientes sometidos a hipotermia terapéutica.

OBJECTIVE: Therapeutic hypothermia (TH) is recommended to minimize neurological damage in patients surviving sudden cardiac arrest (SCA). There is scarcity of data evaluating the nursing workload in these patients. The objective of the study is to assess the workload of nurses whilst treating patients undergoing TH after SCA. METHOD: A 43-month prospective-retrospective comparative cohort study was designed. Patients admitted to intensive care unit, for recovered SCA and persistent coma, were included. A comparison was made using the baseline characteristics, medical management, in-hospital mortality, and nursing workload during the first 96hours using the Therapeutic Intervention Scoring System-28 (TISS-28); Nursing Activities Score (NAS); and Nine Equivalents of Nursing Manpower Use Score (NEMS) scales among patients who received TH and those who did not. RESULTS: A total 46 patients were included: 26 in the TH group and 20 in the Non-TH group. Regarding baseline characteristics and management, the TH group presented higher prevalence of smoking habit (69 vs. 25%, p=0.012), out-of-hospital SCA (96 vs. 55%, p<0.001), and the performance of coronary angiography (96 vs. 65%, p=0.014) compared with the non-TH group. No differences were observed in the nursing workload, assessed by TISS 28, NAS or NEMS scales, or in-hospital mortality. CONCLUSIONS: In this study performance of TH in SCA survivors is not associated with an increase in nursing workload. The installation of a TH program does not require the use of more nursing resources in terms of workload.