Lack of change in the respiratory quotient during oxygen supply dependence in endotoxemic shock: a subanalysis of an experimental controlled study.

OBJECTIVE: To evaluate if the reductions in systemic and renal oxygen consumption are associated with the development of evidence of anaerobic metabolism. METHODS: This is a subanalysis of a previously published study. In anesthetized and mechanically ventilated sheep, we measured the respiratory quotient by indirect calorimetry and its systemic, renal, and intestinal surrogates (the ratios of the venous-arterial carbon dioxide pressure and content difference to the arterial-venous oxygen content difference. The Endotoxemic Shock Group (n = 12) was measured at baseline, after 60 minutes of endotoxemic shock, and after 60 and 120 minutes of fluid and norepinephrine resuscitation, and the values were compared with those of a Control Group (n = 12) without interventions. RESULTS: Endotoxemic shock decreased systemic and renal oxygen consumption (6.3 [5.6 - 6.6] versus 7.4 [6.3 - 8.5] mL/minute/kg and 3.7 [3.3 - 4.5] versus 5.4 [4.6 - 9.4] mL/minute/100g; p < 0.05 for both). After 120 minutes of resuscitation, systemic oxygen consumption was normalized, but renal oxygen consumption remained decreased (6.3 [5.9 - 8.2] versus 7.1 [6.1 - 8.6] mL/minute/100g; p = not significance and 3.8 [1.9 - 4.8] versus 5.7 [4.5 - 7.1]; p < 0.05). The respiratory quotient and the systemic, renal and intestinal ratios of the venous-arterial carbon dioxide pressure and content difference to the arterial-venous oxygen content difference did not change throughout the experiments. CONCLUSION: In this experimental model of septic shock, oxygen supply dependence was not associated with increases in the respiratory quotient or its surrogates. Putative explanations for these findings are the absence of anaerobic metabolism or the poor sensitivity of these variables in detecting this condition.

Lack of change in the respiratory quotient during oxygen supply dependence in endotoxemic shock: a subanalysis of an experimental controlled study / Ausência de alteração no quociente respiratório durante a dependência do suprimento de oxigênio no choque endotoxêmico: subanálise de um estudo experimental controlado

ABSTRACT Objective: To evaluate if the reductions in systemic and renal oxygen consumption are associated with the development of evidence of anaerobic metabolism. Methods: This is a subanalysis of a previously published study. In anesthetized and mechanically ventilated sheep, we measured the respiratory quotient by indirect calorimetry and its systemic, renal, and intestinal surrogates (the ratios of the venous-arterial carbon dioxide pressure and content difference to the arterial-venous oxygen content difference. The Endotoxemic Shock Group (n = 12) was measured at baseline, after 60 minutes of endotoxemic shock, and after 60 and 120 minutes of fluid and norepinephrine resuscitation, and the values were compared with those of a Control Group (n = 12) without interventions. Results: Endotoxemic shock decreased systemic and renal oxygen consumption (6.3 [5.6 - 6.6] versus 7.4 [6.3 - 8.5] mL/minute/kg and 3.7 [3.3 - 4.5] versus 5.4 [4.6 - 9.4] mL/minute/100g; p < 0.05 for both). After 120 minutes of resuscitation, systemic oxygen consumption was normalized, but renal oxygen consumption remained decreased (6.3 [5.9 - 8.2] versus 7.1 [6.1 - 8.6] mL/minute/100g; p = not significance and 3.8 [1.9 - 4.8] versus 5.7 [4.5 - 7.1]; p < 0.05). The respiratory quotient and the systemic, renal and intestinal ratios of the venous-arterial carbon dioxide pressure and content difference to the arterial-venous oxygen content difference did not change throughout the experiments. Conclusion: In this experimental model of septic shock, oxygen supply dependence was not associated with increases in the respiratory quotient or its surrogates. Putative explanations for these findings are the absence of anaerobic metabolism or the poor sensitivity of these variables in detecting this condition.

RESUMO Objetivo: Avaliar se as reduções do consumo de oxigênio sistêmico e renal estão associadas ao desenvolvimento de evidências de metabolismo anaeróbico. Métodos: Esta é uma subanálise de estudo já publicado. Em ovinos anestesiados e ventilados mecanicamente, medimos o quociente respiratório por calorimetria indireta e seus substitutos sistêmicos, renais e intestinais (as razões entre a diferença de pressão venoarterial do teor de dióxido de carbono e a diferença arteriovenosa do teor de oxigênio). O Grupo Choque Endotoxêmico (n = 12) foi medido inicialmente, após 60 minutos do choque endotoxêmico e após 60 e 120 minutos da ressuscitação com fluidos e norepinefrina, e os valores foram comparados com os do Grupo Controle (n = 12) sem intervenções. Resultados: O choque endotoxêmico diminuiu o consumo de oxigênio sistêmico e renal (6,3 [5,6 - 6,6] versus 7,4 [6,3 - 8,5] mL/minuto/kg e 3,7 [3,3 - 4,5] versus 5,4 [4,6 - 9,4] mL/minuto/100g; p < 0,05 para ambos). Após 120 minutos de ressuscitação, o consumo sistêmico de oxigênio foi normalizado, mas o consumo renal de oxigênio permaneceu reduzido (6,3 [5,9 - 8,2] versus 7,1 [6,1 - 8,6] mL/minuto/100g; p = NS e 3,8 [1,9 - 4,8] versus 5,7 [4,5 - 7,1]; p < 0,05). O quociente respiratório e as razões sistêmica, renal e intestinal entre a diferença na pressão venoarterial do teor de dióxido de carbono e a diferença arteriovenosa do teor de oxigênio não se alteraram ao longo dos experimentos. Conclusão: Nesse modelo experimental de choque séptico, a dependência do suprimento de oxigênio não foi associada a aumentos no quociente respiratório ou em seus substitutos. As explicações possíveis para esses achados são a ausência de metabolismo anaeróbico ou a baixa sensibilidade dessas variáveis na detecção dessa condição.

Microcirculatory effects of rewarming in experimental hemorrhagic shock.

BACKGROUND: Rewarming is a recommended therapy during the resuscitation of hypothermic patients with hemorrhagic shock. In experimental models, however, it increases inflammatory response and mortality. Although microcirculation is potential target of inflammation, the microvascular effects of rewarming during the resuscitation of hemorrhagic shock have not been studied. Our goal was to assess the systemic and microcirculatory effects of an increase in core temperature (T°) during the retransfusion of hemorrhagic shock in sheep. Our hypothesis was that rewarming could hamper microcirculation. METHODS: In anesthetized and mechanically ventilated sheep, we measured systemic, intestinal, and renal hemodynamics and oxygen transport. O2 consumption (VO2) and respiratory quotient were measured by indirect calorimetry. Cortical renal, intestinal villi and sublingual microcirculation were assessed by IDF-videomicroscopy. After basal measurements, hemorrhagic shock was induced and T° was reduced to ~33 °C. After 1 h of shock and hypothermia, blood was retransfused and Ringer lactate solution was administered to prevent arterial hypotension. In the control group (n = 12), T° was not modified, while in the intervention (rewarming) group, it was elevated ~3 °C. Measurements were repeated after 1 h. RESULTS: During shock, both groups showed similar systemic and microvascular derangements. After retransfusion, VO2 remained decreased compared to baseline in both groups, but was lower in the control compared to the rewarming group. Perfused vascular density has a similar behavior in both groups. Compared to baseline, it remained reduced in peritubular (control vs. rewarming group, 13.8 [8.7-17.5] vs. 15.7 [10.1-17.9] mm/mm2, PNS) and villi capillaries (14.7 [13.6-16.8] vs. 16.3 [14.2-16.9] mm/mm2, PNS), and normalized in sublingual mucosa (19.1 [16.0-20.3] vs. 16.6 [14.7-17.2] mm/mm2, PNS). CONCLUSIONS: This is the first experimental study assessing the effect of rewarming on systemic, regional, and microcirculatory perfusion in hypothermic hemorrhagic shock. We found that a 3 °C increase in T° neither improved nor impaired the microvascular alterations that persisted after retransfusion. In addition, sublingual mucosa was less susceptible to reperfusion injury than villi and renal microcirculation.

Effects of Systemic Hypothermia on Microcirculation in Conditions of Hemodynamic Stability and in Hemorrhagic Shock.

INTRODUCTION: Although hypothermia is independently associated with an increased mortality in trauma patients, it might be an effective therapeutic approach for otherwise lethal hemorrhage. The effect of hypothermia on microcirculation, however, has been poorly studied in this setting. Our goal was to characterize the effects of hypothermia on microcirculation in normal conditions and in severe hemorrhagic shock. METHODS: In anesthetized and mechanically ventilated sheep, we measured cardiac output (CO), renal blood flow (RBF), and systemic and renal O2 consumption (VO2). Cortical renal, intestinal villi, and sublingual microcirculation was assessed by IDF-videomicroscopy. After basal measurements, sheep were assigned to hypothermia (n = 12) and normothermia (n = 12) groups. Central temperature was reduced to ∼34°C and maintained at baseline in each group, respectively. Measurements were repeated after 1 h of hemodynamic stable conditions and 1 h of severe hemorrhagic shock. RESULTS: In conditions of hemodynamic stability, the hypothermia group showed lower CO, RBF, and systemic and renal VO2 than the normothermia group. Red blood cell velocity was also lower in renal, villi, and sublingual microvascular beds (836 ±â€Š195 vs. 1,066 ±â€Š162, 916 ±â€Š105 vs. 1051 ±â€Š41, and 970 ±â€Š182 vs. 1,102 ±â€Š49 µm/s, respectively; P < 0.0001 for all). In hemorrhagic shock, most of the microvascular variables were similarly compromised in both the groups. In hypo- and normothermia groups, the percentage of reduction in perfused vascular density was higher in renal than in intestinal and sublingual microcirculation (66 ±â€Š31 vs. 31 ±â€Š23 and 15 ±â€Š15%, and 78 ±â€Š26 vs. 32 ±â€Š37 and 18 ±â€Š21%, P < 0.01 for both). CONCLUSIONS: This is the first experimental study assessing the effect of systemic hypothermia on microcirculation in severe hemorrhagic shock. The main finding was that hypothermia did not hamper additionally the microcirculatory derangements induced by hemorrhagic shock. In addition, renal microcirculation was more susceptible to hemorrhagic shock than villi and sublingual microcirculation.

Non-structural protein 1 (NS1) of dengue virus detection correlates with severity in primary but not in secondary dengue infection.

BACKGROUND: Non-structural protein 1 (NS1) of dengue virus circulates in the serum of patients during the acute phase of the disease. OBJECTIVES: To determine whether NS1 screening can serve in diagnosing primary and secondary infection and to evaluate its utility as a marker for predicting the severity of dengue in children. STUDY DESIGN: Patients ≤15 years of age hospitalized for dengue between 2012-2018, with NS1 determination (Panbio, Australia) were included. Clinical y laboratorial characteristics were collected in a standardized data table for analysis of correlation between serotypes, primary or secondary condition of infection, severity, and presence of NS1. RESULTS: Of 709 children hospitalized for dengue with NS1 determination, 479 (67.5 %) had the positive test. Of the 378 primary cases, 320 (85 %) were NS1 (+). while among the 242 secondary cases only 103 (42.5 %) were NS1 (+) (p < 0001). Of the 479 patients with NS1 (+), 344 (72 %) were warnig-signed cases (WSC) and 94 (19 %) were severe cases (SC), being these figures 62 % and 34 %, in the NS1 negative patients respectively (p < 0.001). There was no difference in the frequency of WSC or SC between patients with NS1 positive or negative test in secondary dengue; however, in primary dengue, the figures were 68 % vs 32 % (p < 0.001), and 87 % vs 12 % (p < 0.001), respectively. CONCLUSIONS: The presence of NS1 positive test is associated with the condition of infection (primary or secondary) and exhibited an increased risk of developing forms with warning signs or severe dengue in primary cases, but not in secondary cases.

Effects of fluid and norepinephrine resuscitation in a sheep model of endotoxin shock and acute kidney injury.

The pathophysiology of renal failure in septic shock is complex. Although microvascular dysfunction has been proposed as a mechanism, there are controversial findings about the characteristics of microvascular redistribution and the effects of resuscitation. Our hypothesis was that the normalization of systemic hemodynamics with fluids and norepinephrine fails to improve acute kidney injury. To test this hypothesis, we assessed systemic and renal hemodynamics and oxygen metabolism in 24 anesthetized and mechanically ventilated sheep. Renal cortical microcirculation was evaluated by SDF-videomicroscopy. Shock (n = 12) was induced by intravenous administration of endotoxin. After 60 min of shock, 30 mL/kg of saline solution was infused and norepinephrine was titrated to reach a mean blood pressure of 70 mmHg for 2 h. These animals were compared with a sham group (n = 12). After endotoxin administration, mean blood pressure, cardiac index, and systemic O2 transport and consumption decreased (P < 0.05 for all). Resuscitation improved these variables. Endotoxin shock also reduced renal blood flow and O2 transport and consumption (205[157-293] vs. 131 [99-185], 28.4[19.0-38.2] vs. 15.8[13.5-23.2], and 5.4[4.0-8.8] vs. 3.7[3.3-4.5] mL·min-1·100 g-1, respectively); cortical perfused capillary density (23.8[23.5-25.9] vs. 17.5[15.1-19.0] mm/mm2); and creatinine clearance (62.4[39.2-99.4] vs. 10.7[4.4-23.5] mL/min). After 2 h of resuscitation, these variables did not improve (174[91-186], 20.5[10.8-22.7], and 3.8[1.9-4.8] mL·min-1·100 g-1, 19.9[18.6-22.1] mm/mm2, and 5.9[1.0-11.9] mL/min). In conclusion, endotoxin shock induced severe renal failure associated with decreased renal flow, O2 transport and consumption, and cortical microcirculation. Normalization of systemic hemodynamics with fluids and norepinephrine failed to improve renal perfusion, oxygenation, and function.NEW & NOTEWORTHY This experimental model of endotoxin shock induced severe renal failure, which was associated with abnormalities in renal regional blood flow, microcirculation, and oxygenation. Derangements included the compromise of peritubular microvascular perfusion. Improvements in systemic hemodynamics through fluids and norepinephrine were unable to correct these abnormalities.

Streptococcus constellatus: causa infrecuente de empiema pleural

RESUMEN Streptococcus Constellatus es un microorganismo comensal en el humano, pero puede causar infecciones en diferentes lugares. Reportamos el caso de un escolar con empiema pleural causado por este microorganismo en asociación a anaerobios. El paciente fue tratado con un drenaje pleural y recibió antibioticoterapia durante seis semanas. Fue dado de alta en buenas condiciones. Se discute el caso y se hace revisión de la literatura. Conclusión: En los últimos 5 años, la enfermedad del dengue produce una carga económica y de enfermedad sustancial en Paraguay. Se requiere la sostenibilidad y el fortalecimiento de acciones multisectoriales para reducir el impacto económico del dengue en la población paraguaya.

ABSTRACT Streptococcus constellatus is a commensal microorganism in humans, but it can cause sometimes different types of infections. We report the case of school-age children with pleural empyema caused by this microorganism in association with anaerobic bacteria. The patient was treated with a pleural drainage and received antibiotic therapy for six weeks. It was discharged in good condition. The case is discussed and literature review is done.

Tuberculosis: Factores de riesgo asociados a mortalidad en pacientes ≤19 años hospitalizados en el Instituto de Medicina Tropical / Tuberculosis: Risk factors associated with mortality in patients ≤19 years hospitalized at the Institute of Tropical Medicine

Introducción: La Organización Mundial de la Salud estima que anualmente ocurren 10 millones de casos incidentes de Tuberculosis (TB) en el mundo, de los cuales 10% ocurren en niños <15 años. Las dificultades en el acceso a los establecimientos de salud y el retraso en el diagnóstico y tratamiento apropiados incrementan la mortalidad en el niño. analizar las características Objetivos: clínicas, laboratoriales y los factores asociados a mortalidad en <19 años en pacientes hospitalizados por TB en Instituto de Medicina Tropical. Metodología: estudio observacional descriptivo, retrospectivo. Se incluyeron pacientes con diagnóstico de tuberculosis, hospitalizados, durante los años 2010 a 2018. Los datos fueron obtenidos de base de datos del Departamento de Epidemiología. Las variables incluidas fueron datos demográficos, formas de presentación, diagnostico, tratamiento y factores asociados a la mortalidad. Se realizó análisis descriptivo y analítico. Se considero error alfa < 5%. Resultados: Se identificaron 98 pacientes (pts) ≤19 años, con edad media de 9,3±6,3 años, 65,3% de sexo masculino. El 34,6% con infección por Virus de la inmunodeficiencia humana, y el 23,4% (23/98) con desnutrición. El 42,4% procedían de poblaciones con <100.000 hab y el 23,4% pertenecían a pueblos originarios. El 19,4% (19/98) fallecieron. La mortalidad se asocio a vivienda en poblaciones con <100.000 habitantes (33,3% vs 8,9%, p=0,02. RR=2,3. IC 1,1 ­ 5,0). La mortalidad fue más en la forma de tuberculosis meníngea (46,2% vs 15,3%, p<0,01. RR= 3,0; IC 1,4 ­ 6,5). Conclusiones: La TB predominó en el sexo masculino, más del 80% presento comorbilidades. La mortalidad fue elevada y se asocio a viviendas en aéreas con<100.000 habitantes y la TB meníngea.

Introduction The World Health Organization estimates that 10 million new cases of Tuberculosis occur annually in the world, of which 10% occur in children <15 years of age. Difficulties in accessing health facilities and delaying in the diagnosis and treatment increase mortality in childhood. Objectives: to evaluate the clinical and laboratory characteristics and factors associated with mortality in patients < 19 years of age who were hospitalized for TB at the Institute of Tropical Medicine. Materials and Methods: This was a descriptive, retrospective, observational study. We included hospitalized patients diagnosed with TB during the years 2010 to 2018. The data were obtained from the Hospital Epidemiology Department's database. The variables were demographic data, clinical presentation, diagnosis, treatment and factors associated with mortality. Descriptive and analytical analysis was performed. Alpha error was considered <5%. Results: 98 patients (pts) ≤19 years old were identified, with a mean age of 9.3 ± 6.3 y e a r s , 6 5 . 3 % w e r e m a l e . 3 4 . 6 % h a d h u m a n immunodeficiency virus infection, and 23.4% (23/98) had malnutrition. 42.4% lived in areas with a population with <100,000 inhabitants and 23.4% belonged to native people groups. 19.4% (19/98) died. Mortality was associated with living areas with a population with <100,000 inhabitants (33.3% vs. 8.9%, p = 0.02. RR = 2.3. CI 1.1 - 5.0). Mortality was higher in meningeal tuberculosis presentations (46.2% vs. 15.3%, p <0.01. RR = 3.0; CI 1.4 - 6.5). Conclusions: Tuberculosis predominated in males, more than 80% presented with comorbidities. Mortality was high and was associated with living in areas with <100,000 inhabitants and TB meningeal form.

Características clínicas y manifestaciones infecciosas en pacientes con Enfermedad Granulomatosa Crónica (EGC) en Paraguay

Introducción: La enfermedad granulomatosa crónica (EGC) es causada por un defecto en una de las subunidades de nicotinamida fosfato (NADPH) oxidasa, produciendo en los fagocitos una falla en la producción del superóxido. Como resultado, los pacientes presentan infecciones bacterianas y fúngicas recurrentes. Objetivos: analizar las características clínicas, manifestaciones infecciosas, los microrganismos aislados, así como la evolución de los pacientes que fueron diagnosticados en el Instituto de Medicina Tropical desde en el periodo 1991 - 2017. Materiales y Métodos: fueron incluidos pacientes con diagnóstico de EGC. Se revisaron los expedientes clínicos de pacientes con EGC hospitalizados, se determinaron las características clínico-demográficas, incluyendo la edad del inicio de las manifestaciones clínicas, edad de diagnóstico, antecedentes de consanguinidad en la familia, historia familiar de cuadros similares, manifestaciones clínicas, frecuencia de cuadros infecciosos, complicaciones asociadas a la vacuna BCG, días de hospitalización y evolución de la enfermedad. Resultados: se identificaron 11 pacientes (8 varones y 3 mujeres). Todos los pacientes pertenecían a 8 familias, se identificaron 2 familias con más de un miembro afectado (1 familia con 2 hermanas y otra con 2 primos y una tía afectados). Dos de los 11 pacientes tenían antecedentes de familiares con muerte prematura dentro de las 3 generaciones. La edad media de inicio de síntomas fue de 14.5±10,3 meses y al momento del diagnóstico de 32.4±25,06 meses. En un paciente se identificó antecedentes de consanguinidad, aunque todos recibieron la vacuna BCG, ninguno presento historia de becegeitis. La media de cuadros infecciosos que requirieron hospitalización fue de 3±1,7. Durante el periodo de estudio, los pacientes presentaron 38 cuadros infecciosos. Las infecciones pulmonares fueron las más frecuentemente observadas 42,1% (16/38), incluyendo las neumonías (9/38), absceso pulmonar (1/38), tuberculosis pulmonar (1/38) y bronquiolitis (14/38). Otros cuadros infecciosos que requirieron hospitalización fueron las sepsis 18,4% (7/38), uno de ellos con endocarditis, adenitis 13,2% (5/38), infecciones de piel y partes blandas 13,2% (5/38), meningitis bacteriana y osteomielitis 2,6% (1/38), respectivamente. En 19 de los cuadros infecciosos se aisló el microrganismo causante, siendo el más frecuente el S. aureus (n=9), pero en 10 casos se aisló un microrganismo inusual [Aspergillus (n = 4), Chromobacterium violaceum, Burkholderia cepacia, Enterobacter cloacae, Serratia marcescens, Mycobacterium tuberculosis (uno en cada caso]. El tiempo medio de hospitalización fue de 23,3±14,1 días y la mortalidad acumulada de 3/11. Conclusiones: Coincidente con otras series la mayoría de los casos de EGC, en Paraguay, se observó en varones, y la edad de inicio de síntomas fue antes de los 2 años de edad. El diagnóstico de la enfermedad fue relativamente precoz. El sitio infeccioso más frecuente fue el pulmonar, siendo el microorganismo más frecuentemente aislado el S. aureus, aunque se aislaron microorganismos inusuales en una proporción significativa. Es fundamental considerar esta ID en pacientes con cuadros infecciosos de evolución tórpida y por microorganismos inusuales.

Introduction: Chronic granulomatous disease (CGD) is caused by a defect in one of the subunits of nicotinamide phosphate (NADPH) oxidase, producing a failure in the production of superoxide in phagocytes. As a result, patients have recurrent bacterial and fungal infections. Objectives: to analyze the clinical characteristics, infectious manifestations, the isolated microorganisms, as well as the evolution of patients that were diagnosed at the Institute of Tropical Medicine from 1991 to 2017. Materials and Methods: patients with a diagnosis of CGD were included. Clinical records of hospitalized CGD patients were reviewed, clinical-demographic characteristics were determined, including the age of onset of clinical manifestations, age of diagnosis, family history of consanguinity, family history of similar conditions, clinical manifestations, frequency of infectious diseases, complications associated with the BCG vaccine, hospitalization days and disease evolution. Results: 11 patients were identified (8 men and 3 women). All the patients belonged to 8 families, 2 families were identified who had more than one affected member (1 family with 2 sisters and another with 2 affected cousins and one aunt). Two of the 11 patients had a family history of premature death within 3 generations. The mean age of symptom onset was 14.5 ± 10.3 months and age at the time of diagnosis was 32.4 ± 25.06 months. In one patient, a history of consanguinity was identified; although all patients received the BCG vaccine, none presented a history of BCG adenitis. The mean number of infectious cases that required hospitalization was 3 ± 1.7. During the study period, patients presented with 38 infectious conditions. Pulmonary infections were the most frequently observed 42.1% (16/38), including pneumonia (9/38), lung abscess (1/38), pulmonary tuberculosis (1/38) and bronchiolitis (14/38). Other infectious conditions that required hospitalization were sepsis 18.4% (7/38), one of them with endocarditis, adenitis 13.2% (5/38), skin and soft tissue infections 13.2% (5/38), bacterial meningitis and osteomyelitis 2.6% (1/38), respectively. In 19 of the infectious conditions, the causative microorganism was isolated, the most frequent being S. aureus (n = 9), but in 10 cases an unusual microorganism was isolated [Aspergillus (n = 4), Chromobacterium violaceum, Burkholderia cepacia, Enterobacter cloacae, Serratia marcescens, Mycobacterium tuberculosis (one in each case.)] The mean hospitalization time was 23.3 ± 14.1 days and the accumulated mortality of 3/11. Conclusions: Coinciding with other series, most cases of CGD in Paraguay were observed in males, and the age of onset of symptoms was before 2 years of age.The diagnosis of the disease was made relatively early. The most frequent infectious site were the lungs, with the microorganism most frequently isolated being S. aureus, although unusual microorganisms were isolated in a significant number of cases. It is essential to consider this diagnosis in patients with recurrent bouts of infectious conditions and caused by unusual microorganisms.

Espectro dos efeitos cardiovasculares da dobutamina - de voluntários saudáveis a pacientes em choque séptico / The spectrum of cardiovascular effects of dobutamine - from healthy subjects to septic shock patients

RESUMO A dobutamina é o inotrópico mais comumente utilizado em pacientes com choque séptico, com o objetivo de aumentar o débito cardíaco e corrigir a hipoperfusão. Embora alguns ensaios clínicos tenham demonstrado que a dobutamina pode melhorar a hemodinâmica sistêmica e regional, outras pesquisas identificaram que seus efeitos são heterogêneos e imprevisíveis. Nesta revisão, analisamos as propriedades farmacodinâmicas da dobutamina e seus efeitos fisiológicos. Nosso objetivo foi demonstrar que os efeitos da dobutamina podem diferir entre voluntários saudáveis, estudos experimentais e insuficiência cardíaca clínica, em modelos de estudo em animais e em pacientes com choque séptico. Discutimos as evidências que suportam a afirmativa de que a dobutamina utilizada no tratamento do choque séptico frequentemente se comporta como fármaco cronotrópico e vasodilatador, sem evidências de ação inotrópica. Como seus efeitos colaterais são muito comuns e os benefícios terapêuticos não são claros, sugerimos que ela deve ser utilizada com cautela no choque séptico. Antes de uma decisão terapêutica definitiva, a eficácia e a tolerabilidade da dobutamina devem ser avaliadas por um tempo curto com monitoramento estrito de seus efeitos positivos e efeitos colaterais negativos.

ABSTRACT Dobutamine is the inotrope most commonly used in septic shock patients to increase cardiac output and correct hypoperfusion. Although some experimental and clinical studies have shown that dobutamine can improve systemic and regional hemodynamics, other research has found that its effects are heterogenous and unpredictable. In this review, we analyze the pharmacodynamic properties of dobutamine and its physiologic effects. Our goal is to show that the effects of dobutamine might differ between healthy subjects, in experimental and clinical cardiac failure, in animal models and in patients with septic shock. We discuss evidence supporting the claim that dobutamine, in septic shock, frequently behaves as a chronotropic and vasodilatory drug, without evidence of inotropic action. Since the side effects are very common, and the therapeutic benefits are unclear, we suggest that dobutamine should be used cautiously in septic shock. Before a definitive therapeutic decision, the efficacy and tolerance of dobutamine should be assessed during a brief time with close monitoring of its positive and negative side effects.

The spectrum of cardiovascular effects of dobutamine - from healthy subjects to septic shock patients. / Espectro dos efeitos cardiovasculares da dobutamina - de voluntários saudáveis a pacientes em choque séptico.

Dobutamine is the inotrope most commonly used in septic shock patients to increase cardiac output and correct hypoperfusion. Although some experimental and clinical studies have shown that dobutamine can improve systemic and regional hemodynamics, other research has found that its effects are heterogenous and unpredictable. In this review, we analyze the pharmacodynamic properties of dobutamine and its physiologic effects. Our goal is to show that the effects of dobutamine might differ between healthy subjects, in experimental and clinical cardiac failure, in animal models and in patients with septic shock. We discuss evidence supporting the claim that dobutamine, in septic shock, frequently behaves as a chronotropic and vasodilatory drug, without evidence of inotropic action. Since the side effects are very common, and the therapeutic benefits are unclear, we suggest that dobutamine should be used cautiously in septic shock. Before a definitive therapeutic decision, the efficacy and tolerance of dobutamine should be assessed during a brief time with close monitoring of its positive and negative side effects.

A dobutamina é o inotrópico mais comumente utilizado em pacientes com choque séptico, com o objetivo de aumentar o débito cardíaco e corrigir a hipoperfusão. Embora alguns ensaios clínicos tenham demonstrado que a dobutamina pode melhorar a hemodinâmica sistêmica e regional, outras pesquisas identificaram que seus efeitos são heterogêneos e imprevisíveis. Nesta revisão, analisamos as propriedades farmacodinâmicas da dobutamina e seus efeitos fisiológicos. Nosso objetivo foi demonstrar que os efeitos da dobutamina podem diferir entre voluntários saudáveis, estudos experimentais e insuficiência cardíaca clínica, em modelos de estudo em animais e em pacientes com choque séptico. Discutimos as evidências que suportam a afirmativa de que a dobutamina utilizada no tratamento do choque séptico frequentemente se comporta como fármaco cronotrópico e vasodilatador, sem evidências de ação inotrópica. Como seus efeitos colaterais são muito comuns e os benefícios terapêuticos não são claros, sugerimos que ela deve ser utilizada com cautela no choque séptico. Antes de uma decisão terapêutica definitiva, a eficácia e a tolerabilidade da dobutamina devem ser avaliadas por um tempo curto com monitoramento estrito de seus efeitos positivos e efeitos colaterais negativos.