RESUMEN
The key objective in the hemodynamic treatment of septic shock is the optimization of tissue perfusion and oxygenation. This is usually achieved by the utilization of fluids, vasopressors, and inotropes. Dobutamine is the inotrope most commonly recommended and used for this purpose. Despite the fact that dobutamine was introduced almost half a century ago in the treatment of septic shock, and there is widespread use of the drug, several aspects of its pharmacodynamics remain poorly understood. In normal subjects, dobutamine increases contractility and lacks a direct effect on vascular tone. This results in augmented cardiac output and blood pressure, with reflex reduction in systemic vascular resistance. In septic shock, some experimental and clinical research suggest beneficial effects on systemic and regional perfusion. Nevertheless, other studies found heterogeneous and unpredictable effects with frequent side effects. In this narrative review, we discuss the pharmacodynamic characteristics of dobutamine and its physiologic actions in different settings, with special reference to septic shock. We discuss studies showing that dobutamine frequently induces tachycardia and vasodilation, without positive actions on contractility. Since untoward effects are often found and therapeutic benefits are occasional, its profile of efficacy and safety seems low. Therefore, we recommend that the use of dobutamine in septic shock should be cautious. Before a final decision about its prescription, efficacy, and tolerance should be evaluated throughout a short period with narrow monitoring of its wanted and side effects.
Asunto(s)
Cardiotónicos , Dobutamina , Choque Séptico , Humanos , Gasto Cardíaco/efectos de los fármacos , Cardiotónicos/uso terapéutico , Cardiotónicos/farmacología , Dobutamina/uso terapéutico , Dobutamina/farmacología , Hemodinámica/efectos de los fármacos , Choque Séptico/tratamiento farmacológico , Choque Séptico/fisiopatología , AnimalesRESUMEN
BACKGROUND: There exists limited agreement on the recommendations for the treatment of transitional circulatory instability (TCI) in preterm neonates OBJECTIVE: To compare the efficacy of various interventions used to treat TCI METHODS: Medline and Embase were searched from inception to 21st July 2023. Two authors extracted the data independently. A Bayesian random effects network meta-analysis was used. Recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. INTERVENTIONS: Dopamine, dobutamine, epinephrine, hydrocortisone, vasopressin, milrinone, volume and placebo. MAIN OUTCOME MEASURES: Mortality, major brain injury (MBI) (intraventricular haemorrhage > grade 2 or cystic periventricular leukomalacia), necrotising enterocolitis (NEC) ≥stage 2 and treatment response (as defined by the author). RESULTS: 15 Randomized Controlled Trials (RCTs) were included from the 1365 titles and abstracts screened. Clinical benefit or harm could not be ruled out for the critical outcome of mortality. For the outcome of MBI, epinephrine possibly decreased the risk when compared to dobutamine and milrinone (very low certainty). Epinephrine was possibly associated with a lesser risk of NEC when compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Dopamine was possibly associated with a lesser risk of NEC when compared with dobutamine (very low certainty). Vasopressin possibly decreased the risk of NEC compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Clinical benefit or harm could not be ruled out for the outcome response to treatment. CONCLUSIONS: Epinephrine may be used as the first-line drug in preterm neonates with TCI, the evidence certainty being very low. We suggest future trials evaluating the management of TCI with an emphasis on objective criteria to define it.
Asunto(s)
Cardiotónicos , Recien Nacido Prematuro , Metaanálisis en Red , Vasoconstrictores , Humanos , Recién Nacido , Cardiotónicos/uso terapéutico , Vasoconstrictores/uso terapéutico , Enfermedades del Prematuro/tratamiento farmacológico , Enfermedades del Prematuro/mortalidad , Ensayos Clínicos Controlados Aleatorios como Asunto , Dobutamina/uso terapéutico , Dobutamina/administración & dosificaciónRESUMEN
ABSTRACT: The aim of this study was to synthesize the available evidence regarding differences in the long-term safety and efficacy of intermittent, repeated, or continuous palliative inotropic therapy among patients with advanced heart failure. We systematically searched the PubMed, Embase, and Cochrane Library electronic databases, with a cutoff date of November 23, 2023, for studies reporting outcomes in adult patients with advanced heart failure treated with intermittent, repeated, or continuous levosimendan, milrinone, or dobutamine. Forty-one studies (18 randomized controlled trials and 23 cohort studies) comprising 5137 patients met the inclusion criteria. The results of the network meta-analysis of randomized controlled trials showed that levosimendan had significant advantages over milrinone or dobutamine in reducing mortality and improving left ventricular ejection fraction. A single-arm meta-analysis also indicated that levosimendan had the lowest mortality and significantly improved B-type brain natriuretic peptide and left ventricular ejection fraction. Regarding safety, hypotension events were observed more frequently in the levosimendan and milrinone groups. However, the current evidence is limited by the heterogeneity and relatively small sample size of the studies.
Asunto(s)
Cardiotónicos , Dobutamina , Insuficiencia Cardíaca , Milrinona , Metaanálisis en Red , Simendán , Función Ventricular Izquierda , Humanos , Simendán/uso terapéutico , Simendán/efectos adversos , Simendán/administración & dosificación , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/diagnóstico , Milrinona/efectos adversos , Milrinona/uso terapéutico , Milrinona/administración & dosificación , Cardiotónicos/efectos adversos , Cardiotónicos/uso terapéutico , Cardiotónicos/administración & dosificación , Dobutamina/administración & dosificación , Dobutamina/efectos adversos , Dobutamina/uso terapéutico , Resultado del Tratamiento , Función Ventricular Izquierda/efectos de los fármacos , Ensayos Clínicos Controlados Aleatorios como Asunto , Masculino , Volumen Sistólico/efectos de los fármacos , Recuperación de la Función , Esquema de Medicación , Femenino , Factores de Tiempo , Anciano , Persona de Mediana Edad , Factores de Riesgo , Cuidados PaliativosRESUMEN
Introducción: La insuficiencia adrenal hipotálamo hipofisaria usualmente se manifiesta secundaria a tumores y, cuando resulta congénita se asocia, con frecuencia, con otras deficiencias hormonales. La crisis adrenal suele presentarse en su debut y puede resultar potencialmente mortal. Objetivo: Examinar el caso de una paciente con insuficiencia adrenal central que debutó con una crisis adrenal congénita. Presentación del caso: Recién nacida a término, padres no consanguíneos, hospitalizada a los 9 días de vida por clínica de una semana con múltiples episodios eméticos y apnea. Ingresó con deshidratación severa, hipotensa y estuporosa. Además, se encontró acidosis metabólica severa, hipoglucemia persistente, hiponatremia e insuficiencia prerrenal. Ante la no mejoría de su estado hemodinámico, a pesar del uso de cristaloides y vasopresores, finalmente mejoró con la administración de dosis altas de hidrocortisona. El diagnóstico de deficiencia de cortisol de origen central se realizó con un test dinámico de insulina y la resonancia magnética nuclear hipofisaria. Conclusiones: La crisis adrenal se debe tener presente como diagnóstico diferencial en episodios agudos con inestabilidad hemodinámica persistente e hipoglucemia de difícil manejo. Adicionalmente, hay que considerar que existen otras causas menos comunes de insuficiencia adrenal en neonatos como la hipoplasia hipofisaria(AU)
Introduction: Hypothalamic-pituitary adrenal insufficiency usually manifests secondary to tumors and, when congenital, is often associated with other hormonal deficiencies. Adrenal crisis usually occurs at its onset and can be life threatening. Objective: To review the case of a patient with central adrenal insufficiency who had an onset with a congenital adrenal crisis. Case presentation: Term newborn, non-consanguineous parents, hospitalized at 9 days of life for a week-long clinical presentation with multiple emetic episodes and apnea. She was admitted with severe dehydration, hypotensive and stuporous. In addition, severe metabolic acidosis, persistent hypoglycemia, hyponatremia and prerenal failure were found. Given the lack of improvement of her hemodynamic status, despite the use of crystalloids and vasopressors, she finally improved with the administration of high doses of hydrocortisone. The diagnosis of cortisol deficiency of central origin was made with a dynamic insulin test and pituitary nuclear magnetic resonance imaging. Conclusions: Adrenal crisis should be kept in mind as a differential diagnosis in acute episodes with persistent hemodynamic instability and difficult-to-manage hypoglycemia. Additionally, other less common causes of adrenal insufficiency in neonates, such as pituitary hypoplasia, should be considered(AU)
Asunto(s)
Humanos , Femenino , Recién Nacido , Ceftriaxona/uso terapéutico , Hidrocortisona/uso terapéutico , Insuficiencia Suprarrenal/etiología , Milrinona/uso terapéutico , Dobutamina/uso terapéutico , Vasoconstrictores/uso terapéutico , Unidades de Cuidado Intensivo PediátricoRESUMEN
A insuficiência cardíaca aguda é a principal causa de hospitalização em pacientes acima de 65 anos, além de possuir altos índices de mortalidade hospitalar. Na sua abordagem terapêutica é mandatório um diagnóstico rápido e pronta caracterização do perfil hemodinâmico, baseando-se nos sinais clínicos de congestão e baixo débito cardíaco, para que possamos instituir a terapêutica com drogas endovenosas para alívio rápido dos sintomas, restabelecer a perfusão adequada dos órgãos e reduzir o risco de morte. As drogas a serem administradas de forma isolada ou em combinação são representadas pela furosemida endovenosa em infusão intermitente e contínua, dependendo do grau de congestão pulmonar e/ou sistêmica, as drogas vasodilatadoras e os agentes inotrópicos. As drogas vasodilatadoras, como o nitroprussiato de sódio e a nitroglicerina via endovenosa são, frequentemente, adicionadas aos diuréticos para o tratamento da insuficiência cardíaca aguda com perfil hemodinâmico B, promovendo estabilidade hemodinâmica mais rápida e pronto alívio da dispneia. O nitroprussiato de sódio é preferível nos pacientes com IC perfil B com níveis elevados de resistência vascular periférica e grave congestão pulmonar. Já a nitroglicerina é preferível nos pacientes com cardiopatia isquêmica ou com insuficiência coronariana aguda associada à insuficiência cardíaca. Os agentes inotrópicos positivos estão indicados nos pacientes com IC aguda e evidências de baixo débito cardíaco (perfil hemodinâmico C), a fim de garantir a melhora da perfusão tissular mediante aumento do débito cardíaco, principalmente, nos pacientes hipotensos e com piora da função renal. A associação de inotrópicos com vasodilatadores deve ser considerada quando existe a combinação de baixo débito cardíaco e aumento significativo de resistência vascular pulmonar e ou sistêmica
Acute heart failure is the leading cause of hospitalization in patients over 65 years of age and is accompanied by high hospital mortality rates. In its therapeutic approach, rapid diagnosis and prompt characterization of the hemodynamic profile based on clinical signs of congestion and low cardiac output are mandatory so that we can provide intravenous drug therapy for rapid symptom relief to restore adequate organ perfusion and reduce the risk of death. Drugs to be used alone or in combination are represented by intravenous furosemide in intermittent infusion and continue to depend on the degree of pulmonary and/or systemic congestion, vasodilator drugs, and inotropic agents. Vasodilator drugs, such as sodium nitroprusside and intravenous nitroglycerin, are often added to diuretics for the treatment of acute cardiac insufficiency with hemodynamic profile B, promoting faster hemodynamic stability and prompt relief of dyspnea. Sodium nitroprusside is preferable in patients with hemodynamic profile B with high peripheral vascular resistance and severe pulmonary congestion. Nitroglycerin is preferable in patients with ischemic heart disease or acute coronary insufficiency associated with heart failure (HF). Positive inotropic agents are indicated in patients with acute HF and evidence of low cardiac output (hemodynamic profile C) to ensure improvement in tissue perfusion by increasing cardiac output, especially in patients with hypotension and worsening renal function. The association of inotropes and vasodilators should be considered when there is a combination of low cardiac output and significant increase in pulmonary and/or systemic vascular resistance
Asunto(s)
Humanos , Masculino , Femenino , Vasodilatadores/uso terapéutico , Enfermedad Aguda , Insuficiencia Cardíaca/terapia , Terapéutica , Cardiotónicos , Enfermedades Cardiovasculares , Diuréticos/uso terapéutico , Dobutamina/uso terapéutico , HemodinámicaRESUMEN
La hipertensión pulmonar (HTP), y como consecuencia la disfunción del ventrículo derecho, son importantes factores de riesgo de morbimortalidad en pacientes sometidos a cirugía cardíaca. El tratamiento de la HTP y la disfunción del ventrículo derecho debe ir enfocado a proteger la función cardíaca. Como objetivos principales del manejo hemodinámico se incluye mantener una adecuada precarga del ventrículo derecho, mejorar su función, reducir la poscarga del ventrículo derecho y las resistencias vasculares pulmonares con vasodilatadores. La terapia combinada con fármacos vasodilatadores que presentan diferentes mecanismos de acción es una opción terapéutica emergente en el tratamiento de la HTP. Presentamos el caso de una mujer de 65 años diagnosticada de insuficiencia mitral, aórtica, tricuspídea y con una dilatación de aorta ascendente con HTP sistólica de 115 mmHg estimada mediante ecografía. Se le practicó una plastia mitral, aórtica, tricuspídea y una aortoplastia. En el perioperatorio presentó disfunción del ventrículo derecho e HTP, siendo tratada con óxido nítrico, sildenafilo intravenoso y levosimendán. La evolución fue satisfactoria, manteniéndose el control de la funcionalidad cardíaca y de la HTP sin presentar fenómenos de hipotensión arterial sistémica ni alteraciones respiratorias relevantes (AU)
Pulmonary hypertension (PHT) and the resulting right ventricle dysfunction are important risk factors in patients who undergo cardiac surgery. The treatment of PHT and right ventricle dysfunction should be focused on maintaining the correct right ventricle after load, improving right ventricle function and reducing the right ventricle pre-load and therefore reducing pulmonary vascular resistance by means of vasodilators. A combined therapy of vasodilators and medicines which have different mechanisms of action, is becoming an option for the treatment of PHT. We present a 65 year old woman that suffered from mitral regurgitation, aortic valve disease, tricuspid and ascending aortic dilation with 115 mmHg of pulmonary artery pressure (by ultrasound evaluation). The patient was operated on of mitral, aortic valve and tricuspid plastia and proximal aortic artery plastia as well. Previosly to surgery the patient suffered right ventricle dysfunction and PHT and was treated with nitric oxide, intravenous sildenafil and levosimendan. Subsequent evolution was satisfactory, PHT being controlled, without arterial hypotension nor respiratory alterations (AU)
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Óxido Nítrico/uso terapéutico , Disfunción Ventricular/complicaciones , Disfunción Ventricular/diagnóstico , Disfunción Ventricular/cirugía , Factores de Riesgo , Vasodilatadores/uso terapéutico , Dobutamina/uso terapéutico , Norepinefrina/uso terapéutico , Furosemida/uso terapéutico , Óxido Nítrico/metabolismo , Disfunción Ventricular/tratamiento farmacológico , Indicadores de MorbimortalidadRESUMEN
Objetivou-se avaliar a eficiência do tratamento da hipotensão arterial com eletroacupuntura comparativamente à dobutamina em equinos. Foram avaliados seis cavalos adultos, saudáveis, mantidos em anestesia inalatória, com isofluorano, em ventilação mecânica. Após a estabilização da anestesia, foi induzida hipotensão arterial, através do incremento da concentração do isofluorano, iniciando-se um dos tratamentos: DOB: dobutamina (1,5µg kg-1 min-1, infusão contínua intravenosa); EA: estímulo elétrico no acuponto pericárdio 6 (PC6), bilateralmente; SHAM: estímulo elétrico em ponto falso de acupuntura. Foram mensurados: frequência cardíaca (FC), pressão arterial média (PAM), temperatura retal (T), concentração final expirada de isofluorano (ETiso), variáveis hemogasométricas, concentração sérica de aspartato aminotransferase (AST) e creatina fosfoquinase (CK), tempo e qualidade da recuperação pós-anestésica. Houve incremento na PAM de 50%, 36,6% e 7,5% nos tratamentos DOB, EA e SHAM, respectivamente. Não houve diferença entre os grupos nas variáveis hemogasométricas, FC, T, ETiso, CK, AST, tempo e qualidade de recuperação pós-anestésica. Conclui-se que o tratamento com dobutamina foi mais efetivo para o tratamento da hipotensão em cavalos sob anestesia inalatória quando comparado ao estímulo elétrico do acuponto PC6 ou ponto falso de acupuntura...
This study aimed to evaluate the efficacy of electroacupuncture compared to the dobutamine treatment of hypotension in equines. Six adult horses were maintained in isoflurane anesthesia with mechanical ventilation. After anesthesia was established, the isoflurane concentration was raised until hypotension was achieved. After that the animals were treated with a constant rate of 1.5mg kg -1min-1 intravenous dobutamine (DOB), electroacupunture to pericardium 6 (PC-6) acupoint (EA) and false point treatment (SHAM). Heart rate (HH), median arterial blood pressure (MAP), rectal temperature (T), isoflurane end-tidal concentration, arterial blood gases, creatine kinase (CK), aspartate transaminase (AST), recovery time and quality of recovery were investigated. The MAP increased 50%, 36.5% and 7.5%% in DOB, EA and SHAM treatments, respectively. HH, T, arterial blood gases, CK, AST, recovery time and quality of recovery did not differ among treatments. It was concluded that the dobutamine treatment was more effective than EA and SHAM treatments for the reversion of isoflurane induced hypotension in horses...
Asunto(s)
Animales , Anestesia por Inhalación/efectos adversos , Caballos/cirugía , Dobutamina/uso terapéutico , Electroacupuntura/veterinaria , Hipotensión/terapia , Puntos de Acupuntura , Anestesia General/efectos adversos , Isoflurano/administración & dosificaciónRESUMEN
La ecocardiografía clínica es un método diagnóstico rápido, no invasivo y seguro, realizado a la cabecera del paciente por médicos clínicos no necesariamente especialistas en cardiología y que puede proporcionar una información útil sobre la anatomía cardíaca con estimación de los volúmenes, diámetros, presencia o no de derrame pericárdico y visualización del movimiento de las paredes ventriculares y la función valvular. La medida más práctica de la función ventricular para distinguir entre los pacientes con disfunción sistólica y pacientes con función sistólica conservada es la fracción de eyección del ventrículo izquierdo, que puede estimarse por lo común de forma aproximativa. Los nuevos y pequeños ecocardiógrafos de bolsillo que se encuentran disponibles en los últimos años ofrecen grandes ventajas en cuanto a su disponibilidad, tienen un coste que puede ser considerado accesible en comparación con otros aparatos y aportan la indiscutible ventaja práctica de su portabilidad y su facilidad de uso. La ecocardiografía clínica es perfectamente compatible con la realización posterior de una ecocardiografía experta por personal altamente cualificado (AU)
Clinical echocardiography is a fast, non-invasive and safe diagnostic method carried out at the patients bedside by clinicians, not necessarily cardiologists, and can provide useful information about cardiac anatomy, with estimates of volumes, diameters, the presence or absence pericardial effusion, and visualization of ventricular wall motion and valve function. The most practical measure of ventricular function to distinguish between patients with systolic dysfunction and those with preserved systolic function is ejection fraction, which can be estimated approximately. The new small pocket echocardiography devices that have become available in recent years offer major advantages in terms of availability and their cost can be considered accessible compared with that of other devices. An undisputed practical advantage is their portability and ease of use. Clinical echocardiography is perfectly compatible with the subsequent performance of echocardiography by a highly qualified expert (AU)
Asunto(s)
Anciano , Humanos , Masculino , Persona de Mediana Edad , Arritmias Cardíacas/complicaciones , Arritmias Cardíacas/fisiopatología , Dobutamina/uso terapéutico , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca , Disnea/etiología , Norepinefrina/uso terapéutico , Síndrome Coronario Agudo/complicaciones , Enfermedad Aguda , Contrapulsación , Errores Diagnósticos , Ecocardiografía/instrumentación , Gastroenteritis/diagnóstico , Miocarditis/complicaciones , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico , Embolia Pulmonar , Respiración Artificial , Choque Cardiogénico/etiología , Volumen Sistólico , SístoleRESUMEN
A diferencia del beneficio prolongado en el tiempo que ofrece el tratamiento de la insuficiencia cardíaca (IC) crónica, los tratamientos para la IC aguda evaluados a lo largo de la última década no han demostrado ser capaces (más allá de mejorar en algún caso los síntomas durante el episodio agudo) de reducir el riesgo más elevado de morbimortalidad a medio-largo plazo que experimentan estos pacientes tras un episodio de descompensación. En la actualidad está cobrando fuerza la hipótesis de que para alcanzar este objetivo un tratamiento efectivo debería ser capaz no solo de controlar los síntomas de descompensación, sino también de ofrecer una "protección" prolongada en el tiempo ante los cambios hemodinámicos y la activación secundaria de mecanismos neurohumorales e inflamatorios perjudiciales para el organismo que presentan, durante y tras el episodio clínico de descompensación, los pacientes con IC aguda. La serelaxina, molécula relacionada con el grupo de péptidos endógenos de la familia de la relaxina humana, con múltiples efectos beneficiosos para el miocardio, el árbol vascular y el riñón, además de otros órganos y tejidos, constituye el primer ejemplo documentado de éxito de un tratamiento con este perfil "organoprotector". Su uso en pacientes con IC aguda ha mostrado ya algunos beneficios clínicos prometedores a medio plazo, lo que la convierte en un serio candidato a ocupar un papel de primera línea para mejorar el pronóstico de estos pacientes (AU)
Unlike the prolonged benefit produced by the treatment of chronic heart failure, newer drugs tested for the treatment of acute heart failure in the last decade have failed to provide evidence of clinical benefit beyond some improvement in symptom relief. In particular, no drug has shown the ability to reduce the higher medium- and long-term risk of morbidity and mortality in these patients after an episode of decompensation. Current understanding of the pathophysiology of acute heart failure and its consequences has led to the hypothesis that, beyond symptom control, effective therapies for this syndrome should target not only the hemodynamic changes of the initial phase of the syndrome but should also "protect" the organism from the activation of neurohumoral and inflammatory pathways triggered by the decompensation episode, which persist in time and confer a risk of deleterious effects in several organs and tissues. Serelaxin, a new drug related to the peptidic endogenous hormones of the relaxin family, has recently been shown to provide multiple beneficial effects in terms of "organ protection" - not only in the cardiovascular and renal systems - from these acute heart failure-related deleterious changes. This drug has already been tested in acute heart failure patients with encouraging results in terms of medium-term clinical benefit, rendering serelaxin as a serious candidate for first-line, prognosis-modifying therapy in this syndrome (AU)
Asunto(s)
Humanos , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/fisiopatología , Relaxina/uso terapéutico , Benzazepinas/uso terapéutico , Síndrome Cardiorrenal/etiología , Síndrome Cardiorrenal/prevención & control , Dobutamina/uso terapéutico , Fumaratos/uso terapéutico , Enfermedad Aguda , Amidas/uso terapéutico , Hidrazonas/uso terapéutico , Inflamación , Estimación de Kaplan-Meier , Estudios Multicéntricos como Asunto , Péptido Natriurético Encefálico/uso terapéutico , Pronóstico , Piridazinas/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Proteínas Recombinantes/uso terapéutico , Terapias en InvestigaciónRESUMEN
Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.
Asunto(s)
Humanos , Cardiomiopatías/diagnóstico , Cardiotónicos/uso terapéutico , Dolor en el Pecho/complicaciones , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Dobutamina/uso terapéutico , Ecocardiografía , Cardiopatías Congénitas/diagnóstico , Insuficiencia Cardíaca/diagnóstico , Imagen por Resonancia Magnética , Síndrome Mucocutáneo Linfonodular/complicaciones , Intervención Coronaria Percutánea , Pronóstico , Medición de Riesgo , Función Ventricular Izquierda/fisiologíaRESUMEN
La cardiopatía de Tako-Tsubo es una entidad clínica de reciente descripción puede simular un infarto agudo de miocardio pero con una evolución y pronostico diferentes, generalmente se asocia una situación de estrés desencadenante con bolonamiento apical e hipercontratibilidad compensatoria de los segmentos basales del ventrículo izquierdo pero sin alteraciones significativas en las arteria coronarias.Nosotros reportamos un caso balonamiento apical transitorio del ventrículo izquierdo durante una ecocardiografía de stress con dobutamina cuya recuperación fue a los 15 días.
Asunto(s)
Humanos , Femenino , Anciano , Cardiomiopatía de Takotsubo , Dobutamina/uso terapéutico , Ecocardiografía de EstrésRESUMEN
As doenças cardiovasculares são responsáveis por 34% de todas as causas de morte no Brasil. De acordo com o Ministério da Saúde, foram registrados 500 mil casos de infarto agudo do miocárdio em 1998, com 56 mil óbitos (1). A incidência de choque cardiogênico não sofreu alterações significativas nas últimas três décadas. Ocorre em 5% a 15% dos pacientes com IAM e constitui a principal causa de morte na fase de tratamento hospitalar dos pacientes com infarto agudo do miocárdio
Cardiovascular diseases are responsible for 34% of all causes of deaths in Brazil. According to Department of Health, five hundred thousand of acute myocardial infarction cases in 1998 were registered, resulting in fifty-six thousand deaths related to the disease. The incidence of cardiogenic shock has not meaningful changing in the last three decades. It happens in 5% to 15% with IAM and it's the main cause of deaths with acute myocardial infarction in hospitalar treatment stage
Asunto(s)
Humanos , Masculino , Femenino , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Infarto del Miocardio/complicaciones , Hipoxia/etiología , Cardiotónicos/administración & dosificación , Dobutamina/uso terapéutico , Enfermedades Cardiovasculares/mortalidad , Intubación Intratraqueal , Respiración Artificial , Vasoconstrictores/uso terapéuticoRESUMEN
Diversos estudos relataram os benefícios dos betabloqueadores (BB) para pacientes com insuficiência cardíaca sistólica. No entanto, muitos pacientes hospitalizados em decorrência de insuficiência cardíaca aguda já estão usando os BB e requerem dobutaminas para hipotensão arterial e baixo débito cardíaco. Portanto, deve-se tomar uma decisão a respeito de se o BB deve ser mantido ou até mesmo iniciado nesses casos. O objetivo deste estudo foi determinar se há provas que sustentem a segurança e a eficácia dos BB junto com a dobutamina para pacientes com insuficiência cardíaca aguda descompensada (ICAD). Foi realizada uma pesquisa na literatura de língua inglesa nas bases de dados MEDLINE, ISI Web of Science, Biblioteca Virtual em Saúde, Cochrane Library e o Portal de Revistas Científicas do Capes para identificar estudos relacionados. Literatura adicional foi obtida mediante a análise das respectivas referências encontradas nos artigos identificados. Os resultados esperados incluíram informações sobre o prognóstico (intra-hospitalar e na mortalidade no acompanhamento, número de dias de internação e reinternação), eficácia e segurança (agravamento dos sintomas, choque, intolerância) do uso concomitante desses medicamentos em pacientes hospitalizados com ICAD e baixo débito cardíaco. Esta análise incluiu nove estudos. No entanto, não foram encontrados ensaios clínicos randomizados sobre o assunto. A maioria dos estudos inclui baixo número de pacientes, e não foram encontrados estudos que abordem a segurança do uso concomitante desses medicamentos. Os dados resultantes sugerem que uma cuidadosa revisão da literatura não forneceu evidências para o uso sistemático de BB em pacientes com síndrome de baixo débito cardíaco que necessitam de suporte inotrópico com dobutamina.
Several studies have reported the benefits of beta-blockers (BB) for patients presenting with systolic heart failure. however, many patients hospitalized as a result of acute heart failure are already using BB and require dobutamine for arterial hypotension and low cardiac output. Therefore, a decision must be made regarding whether BB should be maintained or even started in such cases. The aim of this study was to establish whether there is evidence supporting the safety andyeffectiveness of BB together with dobutamine for patients presenting with acute decompensated heart failure (ADHF). We conducted a search of the English-language literature in the databases MEDLINE, ISI Web of Science, Virtual Health Library, Cochrane Library and the CAPES Portal of Scientific Journals to identify related studies. Additional literature was obtained through the review of relevant references in the identified articles. The expected outcomes included information on the prognosis (in-hospital and on follow-up mortality, number of days of hospitalization and readmission),yeffectiveness and safety (worsening of symptoms, shock, intolerance) of the concomitant use of these drugs in hospitalized patients with ADHF and low cardiac output. This review included nine studies. however, no randomized clinical trials on this subject were found. Most studies include a low number of patients, and no studies addressing the safety of the concomitant use of these drugs were found. The resulting data suggest that a careful literature review did not supply evidence for the systematic use of BB in patients with low cardiac output syndrome who require dobutamine for inotropic support.
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Humanos , Antagonistas Adrenérgicos beta/uso terapéutico , Cardiotónicos/uso terapéutico , Dobutamina/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Enfermedad Aguda , Antagonistas Adrenérgicos beta/efectos adversosAsunto(s)
Humanos , Masculino , Lactante , Hemodinámica , Hemodinámica/fisiología , Frecuencia Cardíaca/fisiología , Hipovolemia/complicaciones , Hipovolemia/diagnóstico , Fluidoterapia/métodos , Síndrome de Down/complicaciones , Síndrome de Down/diagnóstico , Albúmina Sérica/administración & dosificación , Albúmina Sérica/uso terapéutico , Frecuencia Cardíaca , Frecuencia Cardíaca/efectos de la radiación , Dobutamina/uso terapéuticoRESUMEN
Na sepse, o mecanismo desencadeador de morte é a disfunção múltipla de órgãos e sistemas. Com isso a microcirculação é considerada o motor na patogênese da sepse. A perfusão microcirculatória representa um dos principais objetivos para melhorar as taxas de sobrevida. Uma vez reconhecida a síndrome séptica, o protocolo clínico estabelece o uso de fluidoterapia com salina, de forma vigorosa na primeira hora e seguida de suporte inotrópico com Dobutamina. A partir daí foi levantada a hipótese das drogas β-agonistas serem relevantes na recuperação da microcirculação, antes mesmo de seu conhecido papel na recuperação do choque cardiogênico. Assim, estudar o papel da Dobutamina, um β-agonista, na resposta adrenérgica em situação de sepse se faz necessário e urgente e o entendimento de sua ação, associada à reposição volêmica, foi objeto deste estudo. Foram usados no presente estudo, 78 hamsters, induzida a endotoxemia com LPS (2mg/kg/de massa de peso corporal) e divididos em 9 grupos: controle (n=10), endotóxico(n=10), endotóxico tratados com Dobutamina na dose de 5 e 15 μg /kg/min (n=10), Isoproterenol(n=10), ressuscitação volêmica (n=10) e ressuscitação volêmica associada à Dobutamina 5 (n=10) e 15 μg/kg/min (n=4) e Isoproterenol (n=4). Foram comparados os resultados de recuperação da densidade capilar funcional ao longo do tempo entre os grupos, e obteve-se resultado estatisticamente significativo no grupo em que se usa Dobutamina de 5μg/kg/min associada à ressuscitação volêmica p< 0,05. Em conclusão este estudo mostra que o papel da ressuscitação volêmica é crucial na resposta da microcirculação para melhorar a densidade capilar funcional, que a velocidade da hemácia capilar tem relação direta com a melhora na perfusão tecidual e que a associação de recuperação volêmica com solução salina e Dobutamina na dose de 5 μg /kg /min melhora significativamente sua resposta e melhora a perfusão.
uring sepsis the mechanism responsible for death is multiple dysfunctions of organs and systems and therefore the microcirculation is considered the motor in the pathogenesis of sepsis and microcirculatory perfusion represents one of the main objectives to improve survival rate. Once one recognizes the septic syndrome, the clinical protocol establishes the use of fluid therapy with physiological saline, in a vigorous way, in the first hour followed by inotropic support with dobutamine. With these facts in mind, our hypothesis is that β-agonist drugs are relevant for microcirculatory recuperation, even before their role was known in the recuperation of cardiogenic shock. In this way, to study the role of dobutamine, a β-agonist, in the adrenergic response in sepsis is needed and urgent. The understanding of its action associated to volume resuscitation was the aim of our study. Seventy-eight male hamsters were used in our study, endotoxemia being induced with LPS (2 mg/kg body weight), divided in 9 groups: control (n=10), endotoxic (n=10), endotoxic treated with dobutamine in the concentrations of 5 and 15 μg/kg/min (n=10, each), isoproterenol (n=10), volume resuscitation associated to dobutamine 5 μg/kg/min (n=10), 15 μg/kg/min (n=4), isoproterenol (n=4) or not (n=10). The microcirculation was observed in the dorsal window chamber and the results compared the recuperation of function capillary density with time and the group treated with dobutamine 5 μg/kg/min associated to volume resuscitation showed a statistically significant improvement (p<0.05) of it. In conclusion, this study has shown that volume resuscitation plays a crucial role in the microcirculatory response in terms of improvement of functional capillary density, the velocity of red blood cells in the capillary has a direct relationship with the improvement of tissue perfusion and the association of volume resuscitation with physiological saline and dobutamine 5 μg/kg/min elicits ...
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Animales , Ratas , Dobutamina/farmacología , Dobutamina/uso terapéutico , Sepsis/sangre , Sepsis/terapia , Agonistas Adrenérgicos beta/administración & dosificación , Agonistas Adrenérgicos beta/uso terapéutico , Capilares/fisiología , Endotoxemia/inducido químicamente , Fluidoterapia/métodos , Microcirculación , Modelos Animales , Soluciones Isotónicas/administración & dosificación , Soluciones Isotónicas/uso terapéuticoRESUMEN
FUNDAMENTO: Há evidências de que a suspensão do betabloqueador (BB) na descompensação cardíaca pode aumentar mortalidade. A dobutamina (dobuta) é o inotrópico mais utilizado na descompensação, no entanto, BB e dobuta atuam no mesmo receptor com ações antagônicas, e o uso concomitante dos dois fármacos poderia dificultar a compensação. OBJETIVO: Avaliar se a manutenção do BB associado à dobuta dificulta a compensação cardíaca. MÉTODOS: Estudados 44 pacientes com FEVE < 45 por cento e necessidade de inotrópico. Divididos em três grupos de acordo com o uso de BB. Grupo A (n=8): os que não usavam BB na admissão; Grupo B (n=25): os que usavam BB, porém foi suspenso para iniciar a dobuta; Grupo C (n=11): os que usaram BB concomitante à dobuta. Para comparação dos grupos, foram utilizados os testes t de Student, exato de Fisher e qui-quadrado. Considerado significante p < 0,05. RESULTADOS: FEVE média de 23,8 ± 6,6 por cento. O tempo médio do uso de dobuta foi semelhante nos três grupos (p=0,35), e o uso concomitante da dobuta com o BB não aumentou o tempo de internação (com BB 20,36 ± 11,04 dias vs sem BB 28,37 ± 12,76 dias, p=NS). Na alta, a dose do BB foi superior nos pacientes em que a medicação não foi suspensa (35,8 ± 16,8 mg/dia vs 23,0 ± 16,7 mg/dia, p=0,004). CONCLUSÃO: A manutenção do BB associado à dobuta não aumentou o tempo de internação e não foi acompanhada de pior evolução. Os pacientes que não suspenderam o BB tiveram alta com doses mais elevadas do medicamento.
BACKGROUND: There is evidence that the suspension of betablockers (BB) in decompensated heart failure may increase mortality. Dobutamine (dobuta) is the most commonly used inotrope in decompensation, however, BB and dobuta act with the same receptor with antagonist actions, and concurrent use of both drugs could hinder compensation. OBJECTIVE: To evaluate whether the maintenance of BB associated with dobuta difficults cardiac compensation. METHODS: We studied 44 patients with LVEF < 45 percent and the need for inotropics. Divided into three groups according to the use of BB. Group A (n=8): those who were not using BB at baseline; Group B (n=25): those who used BB, but was suspended to start dobuta; Group C (n = 11): those who used BB concomitant to dobuta. To compare groups, we used the Student t, Fisher exact and chi-square tests. Considered significant if p < 0.05. RESULTS: Mean LVEF 23.8 ± 6.6 percent. The average use of dobuta use was similar in all groups (p = 0.35), and concomitant use of dobutamine with BB did not increase the length of stay (BB 20.36 ± 11.04 days vs without BB 28.37 ± 12.76 days, p = NS). In the high dose, BB was higher in patients whose medication was not suspended (35.8 ± 16.8 mg/day vs 23.0 ± 16.7 mg/day, p = 0.004). CONCLUSION: Maintaining BB associated with dobutamine did not increase the length of hospitalization and was not associated with the worst outcome. Patients who did not suspend BB were discharged with higher doses of the drug.
FUNDAMENTO: Hay evidencias de que la suspensión del betabloqueante (BB) en la descompensación cardíaca puede aumentar la mortalidad. La dobutamina (dobuta) es el inotrópico más utilizado en la descompensación, mientras tanto, BB y dobuta actúan en el mismo receptor con acciones antagónicas, y el uso concomitante de los dos fármacos podría dificultar la compensación. OBJETIVO: Evaluar si la manutención del BB asociado a la dobuta dificulta la compensación cardíaca. MÉTODOS: Estudiados 44 pacientes con FEVI < 45 por ciento y necesidad de inotrópico. Divididos en tres grupos de acuerdo con el uso de BB. Grupo A (n=8): los que no usaban BB en la admisión; Grupo B (n=25): los que usaban BB, sin embargo fue suspendido para iniciar la dobuta; Grupo C (n=11): los que usaron BB concomitantemente a la dobuta. Para comparación de los grupos, fueron utilizados los test t de Student, exacto de Fisher y qui-cuadrado. Considerado significante P < 0,05. RESULTADOS: FEVI media de 23,8±6,6 por ciento. El tiempo medio de uso de dobuta fue semejante en los tres grupos (p=0,35), y el uso concomitante de la dobuta con el BB no aumentó el tiempo de internación (con BB 20,36 ± 11,04 días vs sin BB 28,37 ± 12,76 días, p=NS). En el alta, la dosis del BB fue superior en los pacientes en que la medicación no fue suspendida (35,8 ± 16,8 mg/día vs 23,0 ± 16,7 mg/día, p=0,004). CONCLUSIÓN: La manutención del BB asociado a la dobuta no aumentó el tiempo de internación y no fue acompañada de peor evolución. Los pacientes que no suspendieron el BB tuvieron alta con dosis más elevadas del medicamento.
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Femenino , Humanos , Masculino , Persona de Mediana Edad , Antagonistas Adrenérgicos beta/efectos adversos , Cardiotónicos/uso terapéutico , Dobutamina/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Privación de Tratamiento , Antagonistas Adrenérgicos beta/administración & dosificación , Antagonistas Adrenérgicos beta/metabolismo , Gasto Cardíaco Bajo/complicaciones , Gasto Cardíaco Bajo/tratamiento farmacológico , Quimioterapia Combinada/efectos adversos , Tiempo de Internación/estadística & datos numéricos , Estudios ProspectivosRESUMEN
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Humanos , Masculino , Persona de Mediana Edad , Oxigenadores de Membrana , Infarto del Miocardio/complicaciones , Infarto del Miocardio/rehabilitación , Trasplante de Corazón/instrumentación , Revascularización Miocárdica/métodos , Revascularización Miocárdica/rehabilitación , Reanimación Cardiopulmonar/instrumentación , Reanimación Cardiopulmonar/métodos , Cuidados Posoperatorios/métodos , Cuidados Posoperatorios/tendencias , Norepinefrina/uso terapéutico , Dobutamina/uso terapéuticoRESUMEN
Introducción y objetivos. Analizar la respuesta contráctil negativa (RCN) del ventrículo izquierdo (VI) en la gated-SPECT con bajas dosis de dobutamina (BDD) en pacientes con miocardiopatía isquémica (MI). Métodos. Se estudió prospectivamente a 68 pacientes (media de edad, 60 ± 11 años; 7 mujeres) con MI mediante gated-SPECT en reposo y durante la infusión de BDD. Se relacionó la RCN (aumento de la puntuación del engrosamiento ≥ 1 unidad) con los criterios gammagráficos de viabilidad y los resultados de la coronariografía. Resultados. El 42,6% (29/68) de los pacientes presentó uno o más segmentos con RCN. En el 14,7% (n = 10) de los pacientes se observó una disminución de la fracción de eyección ≥ 4% con las BDD. Estos pacientes se caracterizaron por tener un mayor número de segmentos con RCN (2,8 ± 2,5 frente a 0,87 ± 0,4; p = 0,042), con un valor de corte en el análisis de curva ROC ≥ 2 segmentos con RCN (sensibilidad, 70%; especificidad, 74%; +LR, 2,71; -LR, 0,40). El 94% (74/79) de los segmentos con RCN correspondía a miocardio vivo (normal o viable gammagráficamente). De los 17 segmentos con acinesia o hipocinesia severa y RCN, 12 (71%) tenían criterios gammagráficos de viabilidad y en su mayoría (10/12) correspondían a territorios con arteria coronaria abierta. Conclusiones. La RCN no es un fenómeno infrecuente en los pacientes con MI y se relaciona con una disminución de la función sistólica general del VI. Mayoritariamente se observa en segmentos con criterios gammagráficos de viabilidad y dependientes de una arteria coronaria abierta (AU)
Introduction and objectives. To investigate negative contractile responses in the left ventricle during low-dose dobutamine (LDD) gated single-photon emission computed tomography (SPECT) in patients with ischemic cardiomyopathy. Methods. Sixty-eight consecutive patients (mean age, 60±11 years; 7 male) with ischemic cardiomyopathy (i.e., left ventricular ejection fraction [LVEF] ≤40%) were evaluated using gated-SPECT at rest and during LDD infusion. Associations between a negative contractile reserve (i.e., a ≥1-grade improvement in wall thickening score with LDD infusion) and scintigraphic viability criteria and coronary angiography findings were analyzed. Results. Some 42.6% (29/68) of patients had a negative contractile reserve in one or more segments. In 14.7% (n=10), the LVEF decreased by ≥4% with LDD. These patients had more segments with a negative contractile reserve (2.8±2.5 vs. 0.87±0.40; P=.042), and the cut-off value on receiver operating characteristic curve analysis was ≥2 segments with a negative contractile reserve (sensitivity 70%, specificity 74%, positive likelihood ratio 2.71, negative likelihood ratio 0.40). Some 94% (74/79) of segments with a negative contractile reserve were in viable myocardium (i.e. normal or viable on scintigraphy). Twelve of 17 segments with akinesia or severe hypokinesia and a negative contractile reserve satisfied scintigraphic viability criteria, with the majority (10/12) lying in territories supplied by a patent coronary artery. Conclusions. A negative contractile reserve was not uncommon in patients with ischemic cardiomyopathy and was associated with a general decrease in left ventricular systolic function. It was observed mainly in myocardial segments that appeared viable on scintigraphy and were supplied by a patent coronary artery (AU)
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Dobutamina/administración & dosificación , Dobutamina/uso terapéutico , Cardiomiopatías/diagnóstico , Cardiomiopatías/terapia , Dosis Mínimas/métodos , Tomografía Computarizada de Emisión de Fotón Único/métodos , Tomografía Computarizada de Emisión de Fotón Único , Perfusión/instrumentación , Perfusión/métodos , Estudios Prospectivos , Relación Dosis-Respuesta a DrogaRESUMEN
El trasplante pulmonar es una opción válida parapacientes con sarcoidosis en estadíos avanzados que sonrefractarios a la terapia médica. Se trata de una enfermedadde etiología desconocida y de evolución y pronósticomuy variables. Así mismo, existe dificultad paradefinir el momento idóneo para la intervención y el tipode trasplante pulmonar a realizar, lo que podría influirsobre la elevada mortalidad perioperatoria de estospacientes. La morbimortalidad postoperatoria se elevaen caso de hipertensión pulmonar pretrasplante y cirugíatorácica previa, así como con la aparición en el postoperatoriode fallo primario del injerto, rechazo agudoe infecciones entre otros factores. Presentamos dos casosclínicos de pacientes diagnosticados de sarcoidosis enestadío terminal, sometidos a trasplante pulmonar ytrasplante cardiopulmonar con diferentes evoluciones,analizando los factores de morbimortalidad que determinaronsu resultado final(AU)
Lung transplantation is an appropriate therapeuticoption for patients with advanced sarcoidosis that hasnot responded to medical treatment. The causes ofsarcoidosis are unknown and the course of disease andprognosis are highly variable. As it is difficult todetermine the ideal timing for a transplant or the type oftransplant to perform, this may influence the highperioperative mortality in these patients. Postoperativemorbidity and mortality rates are high when pulmonaryhypertension is present before the transplant or whenprimary graft failure, acute rejection, infection, or othercomplications develop afterwards. We describe 2patients with a diagnosis of end-stage sarcoidosis whoreceived a lung transplant and a heart-lung transplant.The outcomes were different in each case. We analyzefactors related to morbidity and mortality thatdetermined the outcomes(AU)