Peri-Intubation Adverse Events in the Critically Ill Child After Hematopoietic Cell Transplant.

OBJECTIVES: Mechanically ventilated children post-hematopoietic cell transplant (HCT) have increased morbidity and mortality compared with other mechanically ventilated critically ill children. Tracheal intubation-associated adverse events (TIAEs) and peri-intubation hypoxemia universally portend worse outcomes. We investigated whether adverse peri-intubation associated events occur at increased frequency in patients with HCT compared with non-HCT oncologic or other PICU patients and therefore might contribute to increased mortality. DESIGN: Retrospective cohort between 2014 and 2019. SETTING: Single-center academic noncardiac PICU. PATIENTS: Critically ill children who underwent tracheal intubation (TI). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from the local airway management quality improvement databases and Virtual Pediatric Systems were merged. These data were supplemented with a retrospective chart review for HCT-related data, including HCT indication, transplant-related comorbidity status, and patient condition at the time of TI procedure. The primary outcome was defined as the composite of hemodynamic TIAE (hypo/hypertension, arrhythmia, cardiac arrest) and/or peri-intubation hypoxemia (oxygen saturation < 80%) events. One thousand nine hundred thirty-one encounters underwent TI, of which 92 (4.8%) were post-HCT, while 319 (16.5%) had history of malignancy without HCT, and 1,520 (78.7%) had neither HCT nor malignancy. Children post-HCT were older more often had respiratory failure as an indication for intubation, use of catecholamine infusions peri-intubation, and use of noninvasive ventilation prior to intubation. Hemodynamic TIAE or peri-intubation hypoxemia were not different across three groups (HCT 16%, non-HCT with malignancy 10%, other 15). After adjusting for age, difficult airway feature, provider type, device, apneic oxygenation use, and indication for intubation, we did not identify an association between HCT status and the adverse TI outcome (odds ratio, 1.32 for HCT status vs other; 95% CI, 0.72-2.41; p = 0.37). CONCLUSIONS: In this single-center study, we did not identify an association between HCT status and hemodynamic TIAE or peri-intubation hypoxemia during TI.

Independent association between hypoxemia and night sweats in obstructive sleep apnea.

PURPOSE: To assess the relationship between hypoxemia during polysomnography (PSG) and patient-reported night sweats (NS). METHODS: This retrospective observational study included adult patients who completed a standardized sleep questionnaire and the Epworth Sleepiness Scale (ESS) before PSG. RESULTS: We included 1397 patients (41% women). The median age was 52 years, 80% had obstructive sleep apnea (OSA) defined as an apnea-hypopnea index (AHI) ≥ 5, and 35% were obese. A total of 245 patients (17.5%) reported NS. Their prevalence was higher among patients with OSA compared to controls (18.9% vs. 12.2%, p < 0.01). In the bivariate analysis, the variables associated with NS were BMI, AHI, hypoxemia (T90 ≥ 2.5% of total recording time plus minimum SO2 < 85%), frequent body movements or awakenings, nightmares, excessive daytime sleepiness (Epworth > 10), nocturia, cardiovascular events, and the use of sedatives or antidepressants. In the multivariate model, the independent predictors of NS were BMI (OR: 1.47, CI 95%: 1.07-2.01, p = 0.016), hypoxemia (OR: 1.87, CI 95%: 1.37-2.60, p = 0.0001), nightmares (OR: 2.60, CI 95%: 1.73-3.80, p < 0.0001), frequent body movements and awakenings (OR: 1.57, CI 95%: 1.16-2.11, p = 0.003 and OR: 1.54, CI 95%: 1.13-2.08, p = 0.005, respectively), and excessive daytime sleepiness (OR: 1.65, CI 95%: 1.24-2.20, p = 0.0007). CONCLUSIONS: In patients with OSA, night sweats were significantly and independently associated with a higher hypoxic burden.

Impact of moderate altitude on lung diseases and risk of high altitude illnesses.

A large world population resides at moderate altitudes. In the Valley of Mexico (2240 m above sea level) and for patients with respiratory diseases implies more hypoxemia and clinical deterioration, unless supplementary oxygen is prescribed or patients move to sea level. A group of individuals residing at 2500 or more meters above sea level may develop acute or chronic mountain disease but those conditions may develop at moderate altitudes although less frequently and in predisposed individuals. In the valley of México, at 2200 m above sea level, re-entry pulmonary edema has been reported. The frequency of other altituderelated diseases at moderate altitude, described in skiing resorts, remains to be known in visitors to Mexico City and other cities at similar or higher altitudes. Residents of moderate altitudes inhale deeply the city's air with all pollutants and require more often supplementary oxygen.

Sleep-Disordered Breathing in Adults with Precapillary Pulmonary Hypertension: Prevalence and Predictors of Nocturnal Hypoxemia.

PURPOSE: To evaluate the frequency of sleep-disordered breathing (SDB) and predictors of the presence of nocturnal desaturation in adults with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. METHODS: Outpatients with a hemodynamic diagnosis of precapillary pulmonary hypertension who underwent portable polysomnography were evaluated. Diagnosis and severity of SDB were assessed using three well-established respiratory disturbance index (RDI) thresholds: 5.0/h, 15.0/h, and 30.0/h, while nocturnal hypoxemia was defined by the average oxygen saturation (SpO2) < 90%. Multiple linear regression analysis evaluated the potential relationships among explanatory variables with the dependent variable (average SpO2 values), with comparisons based on the standardized regression coefficient (ß). The R-squared (R2; coefficient of determination) was used to evaluate the goodness-of-fit measure for the linear regression model. RESULTS: Thirty-six adults were evaluated (69.4% females). The majority of the participants (75.0%) had SDB (26 with obstructive sleep apnea [OSA] and one with central sleep apnea [CSA]); while 50% of them had nocturnal hypoxemia. In the linear regression model (R2 = 0.391), the mean pulmonary artery pressure [mPAP] (ß - 0.668; p = 0.030) emerged as the only independent parameter of the average SpO2. CONCLUSION: Our study found that the majority of the participants had some type of SDB with a marked predominance of OSA over CSA, while half of them had nocturnal desaturation. Neither clinical and hemodynamic parameters nor the RDI was a predictor of nocturnal desaturation, except for mPAP measured during a right heart catheterization, which emerged as the only independent and significant predictor of average SpO2.

Varicocele at High Altitude; Venous Outflow Restriction by Hypobaric Hypoxia.

BACKGROUND: Testicular aches have been reported to occur on exposure to high altitude (HA). As a painful expression of venous congestion at the pampiniform plexus, varicocele (VC) might be a consequence of cardiovascular adjustments at HA. Chile's National Social Security Regulatory Body (SUSESO) emphasized evaluating this condition in the running follow-up study "Health effects of exposure to chronic intermittent hypoxia in Chilean mining workers." OBJECTIVES: This study aimed at investigating the prevalence of VC in a population usually shifting between sea level and HA, thereby intermittently being exposed to hypobaric hypoxia. METHODOLOGY: Miners (n=492) agreed to be examined at their working place by a physician, in the context of a general health survey, for the presence of palpable VC, either visible or not. Among them was a group exposed to low altitude (LA) <2,400 m; n=123; another one exposed to moderate high altitude (MHA) working 3,050 m; n=70, and a third one exposed to very high altitude (VHA) >3,900 m, n=165. The Chi2 test and Kruskal-Wallis test were used for the descriptive analyses, and logistic regression was applied to evaluate the association of VC with exposure to HA. The Ethics Committee for Research in Human Beings, Faculty of Medicine, University of Chile, approved this project. RESULTS: VC prevalence (grades 2 and 3) was found to be 10% at LA, 4.1% at MHA, and 16.7% at VHA (p≤0.05). Hemoglobin oxygen saturation (SaO2) was lower, and hemoglobin concentrations were higher in workers with high-grade VC at VHA compared to LA and MHA (Wilcoxon tests, p<0.001). Odds ratios (OR) for the association of VC with HA were 3.7 (95%CI: 1.26 to 12.3) and 4.06 (95%CI: 1.73 to 11.2) for MHA and VHA, respectively. CONCLUSION: Association of VC with HA, a clinically relevant finding, may be related to blood volume centralization mediated by hypobaric hypoxia.

Adaptation to Moderate Altitude Hypoxemia: The Example of the Valley of Mexico.

A large world population resides at moderate altitude. In the Valley of Mexico (2,240 m above sea level), its inhabitants, breathe approximately 29% more on average and have 10% increased hemoglobin concentrations compared to sea level residents, among other differences. These compensations reduce but not eliminate the impact of altitude hypoxemia. The objective of the manuscript is to review and describe the information available on health and disease at moderate altitudes, mainly with data in Spanish language from Latin-American countries. Young adults in Mexico City have an SaO2 between 92% and 94% versus 97% at sea level, frequently decreasing below 90% during sleep and intense exercise. It is likely that among the population living at this altitude, lung growth, and development during pregnancy and infancy are enhanced, and that after residing for several tens of thousands of years, more important adaptations in oxygen transport and utilization have developed, but we are not certain about it. For patients with respiratory diseases, residing at moderate altitudes implies increased hypoxemia and clinical deterioration, unless supplementary oxygen is prescribed or patients move to sea level. Hyperventilation increases exposure of residents to air pollutants compared to those living in cities with similar concentrations of pollutants, although at sea level. Humans evolved at sea level and lack the best-known adaptations to reside at moderate or high altitudes. Residents of moderate altitudes breathe deeply the city´s air with all its pollutants, and more often require supplementary oxygen.

Hypoxemia and Cytokine Storm in COVID-19: Clinical Implications.

One of the most dreadful complications that can occur during the course of COVID-19 is the cytokine storm-also known as cytokine release syndrome-a form of systemic inflammatory response syndrome triggered by SARS-CoV-2 infection. The cytokine storm is an activation cascade of auto-amplifying cytokines, which leads to excessive activation of immune cells and generation of pro-inflammatory cytokines. It occurs when large numbers of white blood cells are activated and release inflammatory cytokines, in turn activating even more white blood cells, finally resulting in an exaggerated pro-inflammatory-mediated response and ineffective anti-inflammatory control, leading to tissue damage, multiorgan failure, acute respiratory distress syndrome and death. Although cytokine storm pathogenesis is multifactorial, we hypothesize there is a close association between hypoxemia and cytokine storms in COVID-19, although it is difficult to establish the direction of this relationship. Most probably they coexist and, given enough time, one triggers the other in a chain reaction. Careful analysis of the day-to-day clinical evolution of COVID-19 indicates that there are short and slight periods of hypoxemia (confirmed by pulse oximetry and arterial gasometry), even on the day of the onset of persistent cough and/or shortness of breath. We propose the use of continuous positive airway pressure in early stages of COVID-19, at the onset of respiratory symptoms. This non-invasive ventilation method may be useful in individualized treatments to prevent early hypoxemia in COVID-19 patients and thus avoid triggering a cytokine storm. We believe such an approach is relevant everywhere, and in Cuba in particular, since the country has initiated national production of mechanical ventilation systems, including non-invasive ventilators. Moreover, as Cuba's COVID-19 protocols ensure early patient admission to isolation centers or hospitals, clinicians can prescribe the early use of continuous positive airway pressure as soon as respiratory symptoms begin, averting early hypoxemia and its triggering effect on cytokine storm development, and consequently, avoiding acute respiratory distress syndrome, multi-organ failure, and death.

Health Effects of Chronic Intermittent Hypoxia at a High Altitude among Chilean Miners: Rationale, Design, and Baseline Results of a Longitudinal Study.

OBJECTIVES: This study aims to assess the health effects on mining workers of exposure to chronic intermittent hypoxia (CIH) at high- and very high-altitude mining compared with similar work at lower altitudes in Chile, and it also aims to constitute the baseline of a 5-year follow-up study. METHODS: We designed a cross-sectional study to assess health conditions in 483 miners working at 2 levels of altitude exposure: 336 working at a very high or high altitude (HA; 247 above 3900-4400 m, and 89 at 3000-3900 m), and 147 below 2400 m. Subjects were randomly selected in two stages. First, a selection of mines from a census of mines in each altitude stratum was made. Secondly, workers with less than 2 years of employment at each of the selected mines were recruited. The main outcomes measured at the baseline were mountain sickness, sleep alterations, hypertension, body mass index, and neurocognitive functions. RESULTS: Prevalence of acute mountain sickness (AMS) was 28.4% in the very high-altitude stratum (P = 0.0001 compared with the low stratum), and 71.7% experienced sleep disturbance (P = 0.02). The adjusted odds ratio for AMS was 9.2 (95% confidence interval: 5.2-16.3) when compared with the very high- and low-altitude groups. Motor processing speed and spatial working memory score were lower for the high-altitude group. Hypertension was lower in the highest-altitude subjects, which may be attributed to preoccupational screening even though this was not statistically significant. CONCLUSIONS: Despite longer periods of acclimatization to CIH, subjects continue to present AMS and sleep disturbance. Compromise of executive functions was detected, including working memory at HA. Further rigorous research is warranted to understand long-term health impacts of high-altitude mining, and to provide evidence-based policy recommendations.

Characteristics and predictors for silent hypoxemia in a cohort of hospitalized COVID-19 patients.

BACKGROUND: An intriguing feature recently unveiled in some COVID-19 patients is the "silent hypoxemia" phenomenon, which refers to the discrepancy of subjective well-being sensation while suffering hypoxia, manifested as the absence of dyspnea. OBJECTIVE: To describe the clinical characteristics and predictors of silent hypoxemia in hospitalized COVID-19 patients. METHODS: We conducted a prospective cohort study including consecutive hospitalized adult (≥ 18 years) patients with confirmed COVID-19 presenting to the emergency department with oxygen saturation (SpO2) ≤ 80% on room air from March 15 to June 30, 2020. We analyzed the characteristics, disease severity, and in-hospital outcomes of patients presenting with dyspnea and those without dyspnea (silent hypoxemia). RESULTS: We studied 470 cases (64.4% men; median age 55 years, interquartile range 46-64). There were 447 (95.1%) patients with dyspnea and 23 (4.9%) with silent hypoxemia. The demographic and clinical characteristics, comorbidities, laboratory and imaging findings, disease severity, and outcomes were similar between groups. Higher breathing and heart rates correlated significantly with lower SpO2 in patients with dyspnea but not in those with silent hypoxemia. Independent predictors of silent hypoxemia were the presence of new-onset headache (OR 2.919, 95% CI 1.101-7.742; P = 0.031) and presenting to the emergency department within the first eight days after symptoms onset (OR 3.183, 95% CI 1.024-9.89; P = 0.045). CONCLUSIONS: Patients with silent hypoxemia sought medical attention earlier and had new-onset headache more often. They were also likely to display lower hemodynamic compensatory responses to hypoxemia, which may underestimate the disease severity.

Severe Acute Respiratory Syndrome Coronavirus 2 Clinical Syndromes and Predictors of Disease Severity in Hospitalized Children and Youth.

OBJECTIVE: To characterize the demographic and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes and identify admission variables predictive of disease severity. STUDY DESIGN: We conducted a multicenter, retrospective, and prospective study of pediatric patients hospitalized with acute SARS-CoV-2 infections and multisystem inflammatory syndrome in children (MIS-C) at 8 sites in New York, New Jersey, and Connecticut. RESULTS: We identified 281 hospitalized patients with SARS-CoV-2 infections and divided them into 3 groups based on clinical features. Overall, 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations including gastrointestinal illness or fever. Patients with MIS-C were more likely to identify as non-Hispanic black compared with patients with respiratory disease (35% vs 18%, P = .02). Seven patients (2%) died and 114 (41%) were admitted to the intensive care unit. In multivariable analyses, obesity (OR 3.39, 95% CI 1.26-9.10, P = .02) and hypoxia on admission (OR 4.01; 95% CI 1.14-14.15; P = .03) were predictive of severe respiratory disease. Lower absolute lymphocyte count (OR 8.33 per unit decrease in 109 cells/L, 95% CI 2.32-33.33, P = .001) and greater C-reactive protein (OR 1.06 per unit increase in mg/dL, 95% CI 1.01-1.12, P = .017) were predictive of severe MIS-C. Race/ethnicity or socioeconomic status were not predictive of disease severity. CONCLUSIONS: We identified variables at the time of hospitalization that may help predict the development of severe SARS-CoV-2 disease manifestations in children and youth. These variables may have implications for future prognostic tools that inform hospital admission and clinical management.

Hipoxemia silenciosa y uso de oxímetro de pulso en el hogar para detección precoz de complicaciones por Covid-19: reporte de un caso y revisión de la literatura / Silent hypoxemia and use of pulse oximeter at home for early detection of complications from Covid-19: a case report and review of the literature

Silent hypoxemia is one of the clinical presentations caused by SARS-CoV-2. It is still considered a medical mystery, as there are inconsistencies between arterial oxygen saturation levels and respiratory symptoms; a clinical scenario that had not been seen before. Their main risk is that it delays medical assistance because they do not have breathing difficulties and, when they consult, the lung damage is quite advanced. The early detection of hypoxia can favor the premature diagnosis of COVID-19 pneumonia and start treatment without delay. The pulse oximeter is presented as a useful, inexpensive, and easy-to-use tool for monitoring oxygen saturation at home in mild illness and detecting silent hypoxemia. This work presents the case of a patient with COVID-19 who, thanks to the use of a pulse oximeter at home, was able to detect silent hypoxemia and favored the early diagnosis of SARS-CoV-2 pneumonia. (AU)

Sleep-disordered breathing and markers of morbidity in children and adolescents with cystic fibrosis.

BACKGROUND: Studies have shown that sleep disorders occur in cystic fibrosis (CF) patients and may be present before daytime clinical manifestations. OBJECTIVES: To evaluate the presence of sleep disorders among children and adolescents with CF, attempting to identify associations with pulmonary function, nutritional status, days in hospital, and days taking antibiotics. METHODS: Individuals with a diagnosis of CF aged between 6 and 18 years were included. Information on sociodemographic, clinical profile, history of hospitalizations, and use of antibiotics in the last year were collected. Spirometry, bioimpedance, and polysomnography were performed. The presence of nocturnal hypoxemia and obstructive sleep apnea syndrome (OSAS) were evaluated and participants divided according to their presence. RESULTS: Thirty-one patients were included. The prevalence of OSAS was 32.3% and nocturnal hypoxemia was 29.0%. Average nocturnal peripheral oxyhemoglobin saturation (SpO2 ) correlated (P < .001) with forced vital capacity (r = .55) and forced expiratory volume in the first second (r = .62). The higher the percentage of total sleep time (TST) with SpO2 less than 90%, the lower the pulmonary function. Individuals with OSAS and nocturnal hypoxemia had lower spirometric values compared to patients without these disorders, but the nocturnal hypoxemia group also had lower Shwachman-Kulczycki score, longer hospitalization time and antibiotic use. TST with SpO2 less than 90% was associated with length of hospitalization (r2 = .53). CONCLUSION: Children and adolescents with CF have sleep disorders, including OSAS (32.3%) and nocturnal hypoxemia (29%). Individuals with nocturnal hypoxemia presented lower lung function, worse clinical score, and higher morbidity. TST with SpO2 less than 90% was associated with length of hospitalization.

Cardiorespiratory Events in Infants Born Preterm during the Transitional Period.

OBJECTIVE: To investigate the features of cardiorespiratory events in infants born preterm during the transitional period, and to evaluate whether different neonatal characteristics may correlate with event type, duration, and severity. STUDY DESIGN: Infants with gestational age (GA) <32 weeks and/or birth weight <1500 g were enrolled in this observational prospective study. Heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded continuously over the first 72 hours. Cardiorespiratory events of ≥10 seconds were clustered into isolated desaturation (SpO2 <85%), isolated bradycardia (HR <100 bpm or <70% of baseline), or combined desaturation/bradycardia and classified as mild, moderate, or severe. The daily incidences of isolated desaturation, isolated bradycardia, and combined desaturation and bradycardia were analyzed. The effects of relevant clinical variables on cardiorespiratory event type and severity were assessed using generalized estimating equations. RESULTS: Among the 1050 events analyzed, isolated desaturations were the most frequent (n = 625) and isolated bradycardias the least common (n = 171). The number of cardiorespiratory events increased significantly from day 1 to day 2 (P = .028). One in 5 events had severe characteristics; event severity was highest for combined desaturation and bradycardia (P < .001). Compared with other event types, the incidence of combined desaturation and bradycardia was inversely correlated with GA (P = .029) and was higher with the use of continuous positive airway pressure (P = .002). The presence of a hemodynamically significant patent ductus arteriosus was associated with the occurrence of isolated desaturations (P = .001) and with a longer duration of cardiorespiratory events (P = .003). CONCLUSIONS: Cardiorespiratory events during transition exhibit distinct types, duration, and severity. Neonatal characteristics are associated with the clinical features of these events, indicating that a tailored clinical approach may reduce the hypoxic burden in preterm infants aged 0-72 hours.

[Risk factors for intraoperative hypoxemia during monopulmonary ventilation: an observational study]. / Fatores de risco para hipoxemia intraoperatória durante ventilação monopulmonar: estudo observacional.

BACKGROUND: Left double-lumen endotracheal tubes have been widely used in thoracic, esophageal, vascular, and mediastinal procedures to provide lung separation. Lacking clear objective guidelines, anesthesiologists usually select appropriately sized double-lumen endotracheal tubes based on their experience with 35 and 37Fr double-lumen endotracheal tubes, which are the most commonly used. We hypothesized the patients with a left main bronchus of shorter length (<40mm) had a greater chance of experiencing desaturation during one lung ventilation, due to obstruction in the orifice of the left upper lobe with the bronchial tube. METHODS: We included 360 patients with a left double-lumen intubated between September 2014 and August 2015. The patient's age, sex, height, weight, and underlying disease were recorded along with type of surgical procedure and the desaturation episodes. In addition, the width of the trachea and the width and length of the left bronchus were measured using computed tomography. RESULT: Patients with a left main bronchus length of less than 40mm who underwent intubation with a left double-lumen endotracheal tubes had significantly higher incidence of desaturation (Odds Ratio (OR: 8.087)) during one-lung ventilation. Other related factors of patients identified to be at risk of developing hypoxia were diabetes mellitus (OR: 5.368), right side collapse surgery (OR: 4.933), and BMI (OR: 1.105). CONCLUSIONS: We identified that patients with a left main bronchus length of less than 40mm have a great chance of desaturation, especially if other desaturation risk factors are present.

Risk factors for intraoperative hypoxemia during monopulmonary ventilation: an observational study / Fatores de risco para hipoxemia intraoperatória durante ventilação monopulmonar: estudo observacional

Abstract Background Left double-lumen endotracheal tubes have been widely used in thoracic, esophageal, vascular, and mediastinal procedures to provide lung separation. Lacking clear objective guidelines, anesthesiologists usually select appropriately sized double-lumen endotracheal tubes based on their experience with 35 and 37 Fr double-lumen endotracheal tubes, which are the most commonly used. We hypothesized the patients with a left main bronchus of shorter length (<40 mm) had a greater chance of experiencing desaturation during one lung ventilation, due to obstruction in the orifice of the left upper lobe with the bronchial tube. Methods We included 360 patients with a left double-lumen intubated between September 2014 and August 2015. The patient's age, sex, height, weight, and underlying disease were recorded along with type of surgical procedure and the desaturation episodes. In addition, the width of the trachea and the width and length of the left bronchus were measured using computed tomography. Result Patients with a left main bronchus length of less than 40 mm who underwent intubation with a left double-lumen endotracheal tubes had significantly higher incidence of desaturation (Odds Ratio (OR: 8.087)) during one-lung ventilation. Other related factors of patients identified to be at risk of developing hypoxia were diabetes mellitus (OR: 5.368), right side collapse surgery (OR: 4.933), and BMI (OR: 1.105). Conclusions We identified that patients with a left main bronchus length of less than 40 mm have a great chance of desaturation, especially if other desaturation risk factors are present.

Resumo Justificativa Os tubos endotraqueais de duplo lúmen (Double-lumen tubes - DLTs) para intubação seletiva esquerda têm sido amplamente utilizados em procedimentos torácicos, esofágicos, vasculares e mediastinais para proporcionar a separação dos pulmões. Com a falta de diretrizes claras, os anestesiologistas geralmente selecionam os tubos com base em sua experiência com os tubos endotraqueais de duplo lúmen de 35 e 37 Fr, os mais comumente usados. Nossa hipótese foi que os pacientes com um brônquio principal esquerdo de menor comprimento (< 40 mm) apresentavam uma chance maior de sofrer dessaturação durante a ventilação monopulmonar, devido à obstrução do orifício do lobo superior esquerdo com o tubo brônquico. Métodos No total, 360 pacientes submetidos à intubação seletiva esquerda mediante o uso de tubo de duplo lúmen foram incluídos no estudo entre setembro de 2014 e agosto de 2015. Idade, sexo, altura, peso e doença de base foram registrados, junto do tipo de procedimento cirúrgico e os episódios de dessaturação. Além disso, a largura da traqueia e a largura e comprimento do brônquio esquerdo foram medidos por meio de tomografia computadorizada. Resultados Os pacientes com comprimento do brônquio principal esquerdo inferior a 40 mm, submetidos à intubação seletiva esquerda com tubos endotraqueais de duplo lúmen, tiveram incidência significativamente maior de dessaturação (Odds Ratio - OR: 8,087) durante a ventilação monopulmonar. Outros fatores relacionados aos pacientes e identificados como risco de desenvolver hipoxemia foram diabetes mellitus (OR: 5,368), cirurgia de colapso direito (OR: 4,933) e IMC (OR: 1,105). Conclusões Identificamos que os pacientes com comprimento do brônquio principal esquerdo inferior a 40 mm apresentam grande chance de dessaturação, principalmente se outros fatores de risco para dessaturação estiverem presentes.

Intermittent Hypoxemia in Infants Born Late Preterm: A Prospective Cohort Observational Study.

OBJECTIVE: To determine if late preterm infants are at increased risk of intermittent hypoxemic events compared with term infants. STUDY DESIGN: Prospective, cohort, observational study of late preterm infants (340/7-366/7 weeks gestational age) and term infants (390/7-416/7 weeks gestational age). Overnight pulse oximetry recordings were performed on days 2-3 after birth, at term equivalent age, and at 45 weeks postmenstrual age. The primary outcome was the frequency of intermittent hypoxemic events per hour (desaturation ≥10% below the preceding baseline SpO2) on the oximetry recording on days 2-3 after birth. Data were analyzed by the Student t test and general linear mixed model. RESULTS: Eighty-five infants were enrolled (late preterm n = 43; term infants n = 42). On days 2-3 after birth, late preterm infants had more intermittent hypoxemic events than term infants (events per hour, mean ± standard error of the mean, 2.5 ± 1.2 vs 1.0 ± 1.2; P < .0001). On mixed model analysis, late preterm infants had a higher frequency of intermittent hypoxemic events at term equivalent age, which decreased to a similar frequency as in term infants by 45 weeks postmenstrual age (events per hour; term equivalent age, late preterm: least squares mean, 3.7 [95% CI, 2.7-5.1] vs term: least squares mean, 1.7 [95% CI, 1.2-2.3]; 45 weeks postmenstrual age, late preterm: least squares mean, 1.5 [95% CI, 1.1-2.1] vs term: least squares mean, 1.9 [95% CI, 1.4-2.6]; P < .0005). CONCLUSIONS: Late preterm infants are at greater risk of intermittent hypoxemia than term infants soon after birth. We speculate that preventing intermittent hypoxemia in late preterm infants may improve neurodevelopmental outcomes.

[Hepatopulmonar syndrome and liver transplantation: experience in the transplantation department of the Guillermo Almenara Irigoyen National Hospital - EsSalud]. / Síndrome hepatopulmonar y trasplante hepático: experiencia en el departamento de trasplantes del Hospital Nacional Guillermo Almenara Irigoyen - EsSalud.

INTRODUCTION: Hepatopulmonary syndrome (HPS) is a serious complication of liver disease, which is characterized by the presence of intrapulmonary vasodilation and progressive hypoxemia. Liver transplantation is the only effective treatment. OBJECTIVE: To show our results of patients with hepatopulmonary syndrome undergoing liver transplantation. MATERIALS AND METHODS: Retrospective, descriptive and cross-sectional study. From March 2000 to December 2016; 226 liver transplants were performed. Of the total, 25 patients were excluded: 12 retransplantation, 9 liver-kidney combined transplants, 2 transplants for acute liver failure, 2 transplants in non-cirrhotic patients. Of the 201 patients with pretransplant diagnosis of liver cirrhosis, 19 filled criteria for SHP; who were distributed according to age, sex, hypoxemia level (pO2), Child-Pugh score and MELD score. The reversibility hypoxemia after liver trasplantation was measured with a cut-off of p02 >75 mmHg. RESULTS: The prevalence of SHP in our series was 9.45%. The average age was 41 years (14-65); the M / F ratio of 1.65. The 78.94% (15/19) were adults. 89.5% (17/19) were Score of Child-Pugh B and C, and 68.4% had severe and very severe SHP. In 94.11% of patients, reversibility SHP founded. The early mortality rate (30 days) in patients with SHP was 10.4%. CONCLUSIONS: The prevalence of HPS in our series was 9.45%. Transplanted patients with and without SHP had similar survival.

Association between Manchester Triage System discriminators and nursing diagnoses. / Associações entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem.

OBJECTIVE: To analyze the association between Manchester Triage System flowchart discriminators and nursing diagnoses in adult patients classified as clinical priority I (emergency) and II (very urgent). METHOD: Cross-sectional study conducted in an emergency department in southern Brazil between April and August 2014. The sample included 219 patients. Data were collected from online patient medical records and data analysis was performed using Fisher's exact test or the chi-square test. RESULTS: 16 discriminators and 14 nursing diagnoses were identified. Associations were found between seven discriminators and five problem-focused nursing diagnoses, including the discriminator Cardiac pain and the diagnosis Acute pain. Three discriminators were associated with four risk nursing diagnoses, among these Acute neurological deficit with the diagnosis Risk of ineffective cerebral tissue perfusion. CONCLUSION: Significant associations were found between Manchester Triage System discriminators and the nursing diagnoses most frequently established in the emergency department.

Presenting Characteristics Associated With Outcome in Children With Severe Traumatic Brain Injury: A Secondary Analysis From a Randomized, Controlled Trial of Therapeutic Hypothermia.

OBJECTIVES: To identify injury patterns and characteristics associated with severe traumatic brain injury course and outcome, within a well-characterized cohort, which may help guide new research and treatment initiatives. DESIGN: A secondary analysis of a phase 3, randomized, controlled trial that compared therapeutic hypothermia versus normothermia following severe traumatic brain injury in children. SETTING: Fifteen sites in the United States, Australia, and New Zealand. PATIENTS: Children (< 18 yr old) with severe traumatic brain injury. MEASUREMENTS AND MAIN RESULTS: Baseline, clinical, and CT characteristics of patients (n = 77) were examined for association with mortality and outcome, as measured by the Glasgow Outcome Scale-Extended Pediatric Revision 3 months after traumatic brain injury. Data are presented as odds ratios with 95% CIs. No demographic, clinical, or CT characteristic was associated with mortality in bivariate analysis. Characteristics associated with worse Glasgow Outcome Scale-Extended Pediatric Revision in bivariate analysis were two fixed pupils (14.17 [3.38-59.37]), abdominal Abbreviated Injury Severity score (2.03 [1.19-3.49]), and subarachnoid hemorrhage (3.36 [1.30-8.70]). Forward stepwise regression demonstrated that Abbreviated Injury Severity spine (3.48 [1.14-10.58]) and midline shift on CT (8.35 [1.05-66.59]) were significantly associated with mortality. Number of fixed pupils (one fixed pupil 3.47 [0.79-15.30]; two fixed pupils 13.61 [2.89-64.07]), hypoxia (5.22 [1.02-26.67]), and subarachnoid hemorrhage (3.01 [1.01-9.01]) were independently associated with worse Glasgow Outcome Scale-Extended Pediatric Revision following forward stepwise regression. CONCLUSIONS: Severe traumatic brain injury is a clinically heterogeneous disease that can be accompanied by a range of neurologic impairment and a variety of injury patterns at presentation. This secondary analysis of prospectively collected data identifies several characteristics associated with outcome among children with severe traumatic brain injury. Future, larger trials are needed to better characterize phenotypes within this population.

Síndrome hepatopulmonar y trasplante hepático: experiencia en el departamento de trasplantes del Hospital Nacional Guillermo Almenara Irigoyen - EsSalud / Hepatopulmonar syndrome and liver transplantation: experience in the transplantation department of the Guillermo Almenara Irigoyen National Hospital - EsSalud

Introducción: El síndrome hepatopulmonar (SHP) es una complicación grave de la enfermedad hepática, la cual se caracteriza por la presencia de vasodilatación intrapulmonar e hipoxemia progresiva, siendo el trasplante de hígado el único tratamiento efectivo. Objetivo: Mostrar nuestros resultados de los pacientes con síndrome hepatopulmonar sometidos a trasplante hepático. Materiales y métodos: Estudio retrospectivo, descriptivo y trasversal. Desde marzo del 2000 a diciembre del 2016 se realizaron 226 trasplantes de hígado. Del total, se excluyeron a 25 pacientes: 12 retrasplantes, 9 trasplantes dobles higadoriñon, 2 trasplantes con falla hepática aguda, 2 trasplantes en pacientes no cirróticos. De los 201 pacientes con diagnóstico pretrasplante de cirrosis hepática, 19 tuvieron criterios de SHP; quienes fueron distribuidos según edad, sexo, nivel de hipoxemia (pO2), score CHILD, score MELD. La reversibilidad de la hipoxemia post trasplante se midió con una cutt off de p0(2) >75 mmHg. Resultados: La prevalencia del SHP en nuestra serie fue 9,45%. La edad promedio fue 41 años (14-65); la relación M/F de 1,65. El 78,94% (15/19) fueron adultos. 89,5% (17/19) fueron score de CHILD B y C, y el 68,4% tuvieron SHP severo y muy severo. En el 94,11% de los pacientes se demostró reversibilidad del SHP. La tasa de mortalidad temprana en los pacientes con SHP fue 10,4%. Conclusiones: La prevalencia del SHP fue del 9,45%. Los pacientes trasplantados con y sin SHP tuvieron similar sobrevida.

Introduction: Hepatopulmonary syndrome (HPS) is a serious complication of liver disease, which is characterized by the presence of intrapulmonary vasodilation and progressive hypoxemia. Liver transplantation is the only effective treatment. Objective: To show our results of patients with hepatopulmonary syndrome undergoing liver transplantation. Materials and methods: Retrospective, descriptive and cross-sectional study. From March 2000 to December 2016; 226 liver transplants were performed. Of the total, 25 patients were excluded: 12 retransplantation, 9 liver-kidney combined transplants, 2 transplants for acute liver failure, 2 transplants in non-cirrhotic patients. Of the 201 patients with pretransplant diagnosis of liver cirrhosis, 19 filled criteria for SHP; who were distributed according to age, sex, hypoxemia level (pO2), Child-Pugh score and MELD score. The reversibility hypoxemia after liver trasplantation was measured with a cut-off of p0(2) >75 mmHg. Results: The prevalence of SHP in our series was 9.45%. The average age was 41 years (14-65); the M / F ratio of 1.65. The 78.94% (15/19) were adults. 89.5% (17/19) were Score of Child-Pugh B and C, and 68.4% had severe and very severe SHP. In 94.11% of patients, reversibility SHP founded. The early mortality rate (30 days) in patients with SHP was 10.4%. Conclusions: The prevalence of HPS in our series was 9.45%. Transplanted patients with and without SHP had similar survival.