Valor prognóstico da disfunção ventricular diastólica em pacientes com sepse grave e choque séptico / Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock

RESUMO Objetivo: Avaliar a prevalência de disfunção miocárdica e seu valor prognóstico em pacientes com sepse grave e choque séptico. Métodos: Pacientes sépticos adultos, admitidos em uma unidade de terapia intensiva, foram estudados de forma prospectiva por meio de ecocardiografia transtorácica dentro das primeiras 48 horas após sua admissão e, então, entre o sétimo e o décimo dias. As variáveis ecográficas de função biventricular, inclusive a relação E/e', foram comparadas entre sobreviventes e não sobreviventes. Resultados: Foi realizado um total de 99 ecocardiogramas (53 na admissão e 46 entre os dias 7 e 10) em 53 pacientes com média de idade de 74 anos (desvio padrão de 13 anos). Estava presente disfunção sistólica em 14 (26%); disfunção diastólica foi observada em 42 (83%) pacientes; e ambos os tipos de disfunção estavam presentes em 12 (23%) pacientes. A relação E/e', ou índice de disfunção diastólica, foi o melhor preditor de mortalidade hospitalar segundo a área sob a curva ROC (0,71) e se constituiu em um preditor independente do desfecho, conforme determinado pela análise multivariada (odds ratio - OR = 1,36 [1,05 - 1,76]; p = 0,02). Conclusão: Em pacientes sépticos admitidos em uma unidade de terapia intensiva, a disfunção sistólica determinada ecograficamente não se associa com aumento da mortalidade. Em contraste, a disfunção diastólica foi um preditor independente do desfecho.

ABSTRACT Objectives: To evaluate the prevalence of myocardial dysfunction and its prognostic value in patients with severe sepsis and septic shock. Methods: Adult septic patients admitted to an intensive care unit were prospectively studied using transthoracic echocardiography within the first 48 hours after admission and thereafter on the 7th-10th days. Echocardiographic variables of biventricular function, including the E/e' ratio, were compared between survivors and non-survivors. Results: A total of 99 echocardiograms (53 at admission and 46 between days 7 - 10) were performed on 53 patients with a mean age of 74 (SD 13) years. Systolic and diastolic dysfunction was present in 14 (26%) and 42 (83%) patients, respectively, and both types of dysfunction were present in 12 (23%) patients. The E/e' ratio, an index of diastolic dysfunction, was the best predictor of hospital mortality according to the area under the ROC curve (0.71) and was an independent predictor of outcome, as determined by multivariate analysis (OR = 1.36 [1.05 - 1.76], p = 0.02). Conclusion: In septic patients admitted to an intensive care unit, echocardiographic systolic dysfunction is not associated with increased mortality. In contrast, diastolic dysfunction is an independent predictor of outcome.

The Effects of Arterial Hypertension and Age on the Sublingual Microcirculation of Healthy Volunteers and Outpatients with Cardiovascular Risk Factors.

OBJECTIVES: To quantitatively assess the effects of age, blood pressure, chronic arterial hypertension, and physical activity on sublingual microcirculation in ambulatory volunteers. METHODS: Sublingual microcirculation was assessed in 61 volunteers with or without chronic arterial hypertension. RESULTS: Volunteers with chronic arterial hypertension had lower TVD all vessels, and TVD small vessels and PVD small vessels than those without this condition (16.0 ± 1.4 vs. 17.2 ± 1.6 mm/mm(2), p < 0.01, 15.1 ± 1.3 vs. 16.1 ± 1.7 mm/mm(2), p < 0.04, and 15.1 ± 1.3 vs. 16.1 ± 1.7 mm/mm(2), p < 0.04, respectively). Mean blood pressure correlated with TVD all vessels (r = -0.34, p < 0.01), TVD small vessels (r = -0.31, p < 0.02), and PVD small vessels (r = -0.27, p < 0.04) but not with other microvascular variables. Age was not correlated with any microcirculatory variables. Physical activity correlated with TVDall vessels and RBCV small vessels (r = 0.30, p < 0.02 and r = -0.47, p < 0.001, respectively). Chronic arterial hypertension was the only independent determinant of PVD small vessels . CONCLUSIONS: Preexistent chronic arterial hypertension was associated with lower vascular densities. In contrast, age showed no effect on sublingual microcirculation.

Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock.

OBJECTIVES: To evaluate the prevalence of myocardial dysfunction and its prognostic value in patients with severe sepsis and septic shock. METHODS: Adult septic patients admitted to an intensive care unit were prospectively studied using transthoracic echocardiography within the first 48 hours after admission and thereafter on the 7th-10th days. Echocardiographic variables of biventricular function, including the E/e' ratio, were compared between survivors and non-survivors. RESULTS: A total of 99 echocardiograms (53 at admission and 46 between days 7 - 10) were performed on 53 patients with a mean age of 74 (SD 13) years. Systolic and diastolic dysfunction was present in 14 (26%) and 42 (83%) patients, respectively, and both types of dysfunction were present in 12 (23%) patients. The E/e' ratio, an index of diastolic dysfunction, was the best predictor of hospital mortality according to the area under the ROC curve (0.71) and was an independent predictor of outcome, as determined by multivariate analysis (OR = 1.36 [1.05 - 1.76], p = 0.02). CONCLUSION: In septic patients admitted to an intensive care unit, echocardiographic systolic dysfunction is not associated with increased mortality. In contrast, diastolic dysfunction is an independent predictor of outcome.

Adequate systemic perfusion maintained by a CentriMag during acute heart failure.

Mechanical circulatory support during severe acute heart failure presents options for myocardial recovery or cardiac replacement. Short-term circulatory support with the newest generation of magnetically levitated centrifugal-flow pumps affords several potential advantages. Herein, we present our experience with such a pump-the CentriMag Levitronix LLC; Waltham, Mass) centrifugal-flow ventricular assist device-in 4 critically ill patients who were in cardiogenic shock. From November 2007 through March 2008, 3 patients were supported after cardiac surgery, and 1 after chronic heart failure worsened. Two patients were bridged to heart transplantation, and 2 died during support. Perfusion during support was evaluated in terms of serum lactic acid levels and oxygenation values. In all of the patients, the CentriMag's pump flow was adequate, and continuous mechanical ventilation support was provided. Lactic acid levels substantially improved with CentriMag support and were maintained at near-normal levels throughout. At the same time, arterial pH, PO2, and carbon dioxide levels remained within acceptable ranges. No thromboembolic events or mechanical failures occurred. Our experience indicates that short-term use of the CentriMag ventricular assist device during acute heart failure can restore and adequately support circulation until recovery or until the application of definitive therapy.

Central venous to mixed venous blood oxygen and lactate gradients are associated with outcome in critically ill patients.

OBJECTIVE: Blood O(2) saturation and lactate concentration gradients from superior vena cava (SVC) to pulmonary artery (PA) occur in critically ill patients. These gradients (DeltaSO(2) and Delta[Lac]) may be positive or negative. We tested the hypothesis that positive DeltaSO(2) and Delta[Lac] are associated with improved survival in critically ill patients. DESIGN AND SETTING: Multinational, prospective observational study conducted in six medical and surgical ICUs. PATIENTS: Consecutive sample of 106 adults requiring insertion of a pulmonary artery catheter (PAC). Average age was 59.5 +/- 15.5 years, APACHE II score was 15.5 +/- 6.7 (mean +/- SD). Main outcome measure was 28-day mortality. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We drew blood samples from the proximal and distal ports of PACs every 6 h from the time of PAC insertion (Initial measurement) until its removal (Final measurement). Samples were analyzed for SO(2), [Lac], glucose concentration and blood gases. Hemodynamic measurements were obtained after blood samples. We monitored patients for 30.9 +/- 11.0 h. Overall mortality rate was 25.5%. More survivors had mean and final DeltaSO(2) > or = 0 and Delta[Lac] > or = 0 than decedents (p < 0.01; p < 0.05 respectively). On the average, DeltaSO(2) and Delta[Lac] were positive in survivors and negative in decedents. Survival odds ratios for final measurements of DeltaSO(2) > or = 0 and Delta[Lac] > or = 0 were 19.22 and 7.70, respectively (p < 0.05). CONCLUSIONS: A strong association exists between positive DeltaSO(2) and Delta[Lac] and survival in critically ill patients. Whether therapy aimed at increasing DeltaSO(2) and Delta[Lac] results in improved ICU survival remains to be determined.

Empleo preoperatorio preventivo (profiláctico) de balón de contrapulsación (EPPreBa) / Preoperatory (prophylactic) employment of counterpulsation intraortic ballon

Introducción: En los últimos años, diversos estudios postulan el empleo preoperatorio del balón de contrapulsación. La mayoría de ellos resultan consideraciones retrospectivas ó estudios unicéntricos que incluyeron en su población pacientes con indicaciones terapéuticas del dispositivo (angina refractaria). Objetivo: Valorar la utilización preoperatoria (profiláctica) del balón considerando: a)mortalidad, b)síndrome de bajo volumen minuto y c)complicaciones asociadas con el dispositivo. Material y métodos: Entre el 1° de mayo de 1999 y el 1° de febrero de 2002 se incluyó el total de cirugías cardíacas bajo circulación extracorpórea. Se definieron de alto riesgo los pacientes portadores de dos de las siguientes variables: deterioro severo de la función ventricular, lesión severa de tronco, reoperación, anatomía coronaria difusa y edad mayor de 75 años. Los mismos fueron aleatorizados a empleo preoperatorio de balón versus su utilización según necesidad en el intraoperatorio o el posoperatorio. Se excluyeron los pacientes con indicaciones terapéuticas. Se consideró significativo un valor de p menor de 0,05. Resultados: Doscientos veintrés (223) pacientes reunieron los criterios de alto riesgo, los cuales fueron aleatorizados a balón preoperatorio (111 pacientes) versus su empleo según necesidad (112 pacientes, grupo control). La mortalidad total fue de 25 pacientes (11,2 por ciento), 8 del grupo balón preoperatorio (7,2 por ciento) y 17 del grupo control (15,2 por ciento; p = 0,05). En el grupo preoperatorio también fue inferior la incidencia de bajo volumen minuto: 11 pacientes (9,9 por ciento) versus 27 pacientes (24,1 por ciento; p = 0,004). Se observaron 7 complicaciones vinculadas al dispositivo (3,1 por ciento), isquemia del miembro en 5 casos e infecciones localizadas en el acceso vascular en 2. No se observaron muertes vinculadas al dispositivo. Conclusiones: 1. El empleo preoperatorio del balón se asoció con la reducción en la mortalidad e incidencia menor de bajo volumen minuto perioperatorio. 2. La incidencia de complicaciones resultó baja: 7 pacientes (3,1 por ciento)

Empleo preoperatorio preventivo (profiláctico) de balón de contrapulsación (EPPreBa) / Preoperatory (prophylactic) employment of counterpulsation intraortic ballon

Introducción: En los últimos años, diversos estudios postulan el empleo preoperatorio del balón de contrapulsación. La mayoría de ellos resultan consideraciones retrospectivas ó estudios unicéntricos que incluyeron en su población pacientes con indicaciones terapéuticas del dispositivo (angina refractaria). Objetivo: Valorar la utilización preoperatoria (profiláctica) del balón considerando: a)mortalidad, b)síndrome de bajo volumen minuto y c)complicaciones asociadas con el dispositivo. Material y métodos: Entre el 1º de mayo de 1999 y el 1º de febrero de 2002 se incluyó el total de cirugías cardíacas bajo circulación extracorpórea. Se definieron de alto riesgo los pacientes portadores de dos de las siguientes variables: deterioro severo de la función ventricular, les