Intracranial Hypertension and Intra-abdominal Pressure. Is it Worth Measuring?

Patients with refractory intracranial hypertension who have already undergone all the measures recommended by the current guidelines can benefit from having their intraabdominal pressure monitored since its increase generates hemodynamic repercussions and secondary elevation of intracranial pressure. In this context, a bibliographic research was performed on PubMed with the terms intra-abdominal pressure, abdominal compartment syndrome, intracranial pressure, intracranial hypertension. Altogether, 146 articles were observed, 87 of which were from the year 2000, and only 15 articles were considered relevant to the topic. These studies indicate that patients with refractory intracranial hypertension can benefit fromthe measurement of intraabdominal pressure, since there is evidence that an increase in this pressure leads to organic dysfunctions with an indirect impact on cerebral venous return and, consequently, an increase in intracranial pressure. In thosewho underwent decompression laparotomy, direct effectswere observed in reducing intracranial hypertension and survival.

Gastrostomia e jejunostomia: aspectos da evolução técnica e da ampliação das indicações / Gastrostomy and jejunostomy: aspects of the technical evolution and widening of indications

O acesso à luz do estômago e do jejuno proximal por meio de gastrostomia e jejunostomia, respectivamente, de forma temporária ou definitiva, está indicado diante da necessidade prolongada de descompressão digestiva ou de suporte alimentar. O emprego desses procedimentos expandiu-se nos últimos 25 anos com a introdução da gastrostomia endoscópica, especialmente em pacientes com afecções neurológicas de evolução progressiva e neoplasias avançadas. Este artigo aborda aspectos conceituais da gastrostomia e jejunostomia, as principais indicações, as vias de acesso preferenciais em diferentes cenários clínicos e as modalidades técnicas frequentemente empregadas. O manejo dessas estomias, os resultados e as potenciais complicações também são enfatizados. Finalmente, os fundamentos éticos e legais da ampliação da indicação da gastrostomia e da jejunostomia como procedimentos paliativos são discutidos.

A temporary or permanent access to the stomach or jejunum, through a gastrostomy or jejunostomy, is indicated whenever nutritional support or prolonged decompression of the upper alimentary tract is needed. With the introduction of endoscopic gastrostomy, the utilization of these procedures has increased in the last 25 years, specially in patients with progressive neurologic diseases and in those with advanced cancer. This article deals with the conceptual aspects of gastrostomies and jejunostomies, its primary indications, the preferential means of access in different clinical scenarios as well as the technical modalities most frequently used. The management of the stomas, the results and potential complications are also highlighted. Finally, the ethical and legal implications of greater utilization of these procedures in a palliative setting are also discussed.

Úlceras por pressão / Pressure sores

Dentre o amplo espectro das chamadas feridas complexas a úlcera por pressãopode ser definida como uma lesão localizada, acometendo pele e/ou tecidos subjacentes, usualmente sobre uma proeminência óssea, resultante de pressão, ou pressão associada a cisalhamento e/ou fricção. Os fatores de risco para úlceras por pressão são todos aqueles que predispõem o indivíduo a períodos prolongados de isquemia induzida por pressão, e que reduzem a capacidade de recuperação tecidual da lesão isquêmica, podendo ter fatoresassociados intrínsecos ou extrínsecos. A classificação de ulceras por pressão e as medidas de prevenção são inúmeras. Contudo, para ulceras por pressão com complicações ou profundidades avançadas o tratamento determinante na sua resolução é o cirúrgico. Nos últimos anos, a introdução da pressão negativa para o tratamento de feridas complexas, como são para muitas úlceras por pressão, foi muito importante como adjuvante no tratamento cirúrgico...

Among the broad spectrum of complex wounds the pressure ulcer can be defined as a localized lesion, affecting the skin and/or underlying tissue usually over a bony prominence,resulting from pressure or pressure combined with shear and/or friction. Risk factors for pressure ulcers are those that predispose an individual to prolonged periods of ischemia induced by pressure, and reduce the ability of the tissue recovery of a ischemic injury, which can have associated factors, intrinsic or extrinsic. The classification of pressure ulcers and prevention scales are numerous. However, for pressure ulcers with complications or advanced depths the determinant treatment is surgery. In recent years, the introduction of negative pressuredressing for treatment of complex wounds, as are many pressure ulcers, was very important as an adjuvant therapy surgery...

Tratamento do trauma cranioencefálico grave com descompressão abdominal não-cirúrgica no cão: relato de caso / Treatment of severe head trauma using nonsurgical abdominal decompression in a dog: case report

O traumatismo cranioencefálico (TCE) é uma síndrome grave, associada a alta mortalidade tanto em humanos quanto em animais de companhia. A causa mais comum em cães e gatos é o trauma por atropelamento, seguida dos ferimentos a bala, acidentes por mordedura e quedas. Descreve-se um caso de TCE grave em um cão sem raça definida, com três anos de idade, que apresentou evolução desfavorável após a abordagem inicial, com redução da escala de coma de Glasgow ao nível mínimo (3 pontos), mesmo após o tratamento clínico e cirúrgico padrão. A terapêutica adicional envolveu o controle da pressão intra-abdominal por meio de sondagem nasogástrica, com o objetivo de descomprimir o abdômen e melhorar a perfusão cerebral(AU)

Head trauma is a severe syndrome, associated to high mortality in humans and in veterinary medicine. The mosts common causes in dogs and cats are vehicle accidents, followed by gunshot wounds, bit injuries, falls from height, and human violence. This is a report of a severe head injured 3 years old dog, with consciousness and a Glasgow coma scale of 3 points at presentation that developed a non satisfactory clinica course even after all routine clinical and surgical maneuvers. Additional novel therapeutic approach involved the abdominal pressure control by nasogastric aspiration, looking for abdominal decompression in order to improve cerebral perfusion(AU)

Tratamento do trauma cranioencefálico grave com descompressão abdominal não-cirúrgica no cão: relato de caso / Treatment of severe head trauma using nonsurgical abdominal decompression in a dog: case report

O traumatismo cranioencefálico (TCE) é uma síndrome grave, associada a alta mortalidade tanto em humanos quanto em animais de companhia. A causa mais comum em cães e gatos é o trauma por atropelamento, seguida dos ferimentos a bala, acidentes por mordedura e quedas. Descreve-se um caso de TCE grave em um cão sem raça definida, com três anos de idade, que apresentou evolução desfavorável após a abordagem inicial, com redução da escala de coma de Glasgow ao nível mínimo (3 pontos), mesmo após o tratamento clínico e cirúrgico padrão. A terapêutica adicional envolveu o controle da pressão intra-abdominal por meio de sondagem nasogástrica, com o objetivo de descomprimir o abdômen e melhorar a perfusão cerebral

Head trauma is a severe syndrome, associated to high mortality in humans and in veterinary medicine. The mosts common causes in dogs and cats are vehicle accidents, followed by gunshot wounds, bit injuries, falls from height, and human violence. This is a report of a severe head injured 3 years old dog, with consciousness and a Glasgow coma scale of 3 points at presentation that developed a non satisfactory clinica course even after all routine clinical and surgical maneuvers. Additional novel therapeutic approach involved the abdominal pressure control by nasogastric aspiration, looking for abdominal decompression in order to improve cerebral perfusion

Acute reduction of ventricular volume decreases QT interval dispersion in elderly subjects with and without heart failure.

To evaluate the effects of acute reduction in ventricular volume (VV) on QT interval dispersion (QTd), 14 men with heart failure (HF; 74.5 +/- 2 yr of age) and 11 healthy male control subjects (68 +/- 2 yr of age) were studied. For 15 min, lower body negative pressure (LBNP) was applied at -15 and -40 mmHg to reduce venous return. At baseline and during LBNP application, QTd was measured with an 87-lead, body-surface-mapping device; chamber volumes were assessed by radioisotope ventriculography; blood pressure (BP) and heart rate (HR) were continuously monitored; and blood samples were obtained for assessment of norepinephrine (Nor) levels. At -15 mmHg, LNBP application induced a significant decrease in VV but did not change BP and HR in both groups. In addition, Nor levels increased significantly (P < or = 0.05) in the control group (from 286.7 +/- 31.5 to 388.8 +/- 41.2 pg/ml) and in HF patients (from 405.8 +/- 56 to 477.6 +/- 47 pg/ml), and QTd was significantly (P < or = 0.05) decreased in the control group (57.2 +/- 3.8 vs. 49.1 +/- 3.4 ms) and in HF patients (67.8 +/- 6 vs. 63.7 +/- 5.9 ms). No additional decreases in VV or QTd were produced by -40 mmHg LNBP, but Nor levels did increase in both groups and reach 475.5 +/- 34 and 586.5 +/- 60 pg/ml (P < 0.05) in the control and HF groups, respectively; BP did not change, but HR also increased in both groups. In conclusion, an acute LBNP-induced reduction in VV caused a decrease in the QTd of elderly men regardless of the existence of HF. Because increased sympathetic activity with more intense LBNP was not accompanied by additional changes in QTd, altered QTd may be better related to changes in VV than to autonomic nervous system activity.

Pressure and time dependence of the cardiopulmonary reflex response in patients with hypertensive cardiomyopathy.

The first minutes of the time course of cardiopulmonary reflex control evoked by lower body negative pressure (LBNP) in patients with hypertensive cardiomyopathy have not been investigated in detail. We studied 15 hypertensive patients with left ventricular dysfunction (LVD) and 15 matched normal controls to observe the time course response of the forearm vascular resistance (FVR) during 3 min of LBNP at -10, -15, and -40 mmHg in unloading the cardiopulmonary receptors. Analysis of the average of 3-min intervals of FVR showed a blunted response of the LVD patients at -10 mmHg (P = 0.03), but a similar response in both groups at -15 and -40 mmHg. However, using a minute-to-minute analysis of the FVR at -15 and -40 mmHg, we observed a similar response in both groups at the 1st min, but a marked decrease of FVR in the LVD group at the 3rd min of LBNP at -15 mmHg (P = 0.017), and -40 mmHg (P = 0.004). Plasma norepinephrine levels were analyzed as another neurohumoral measurement of cardiopulmonary receptor response to LBNP, and showed a blunted response in the LVD group at -10 (P = 0.013), -15 (P = 0.032) and -40 mmHg (P = 0.004). We concluded that the cardiopulmonary reflex response in patients with hypertensive cardiomyopathy is blunted at lower levels of LBNP. However, at higher levels, the cardiopulmonary reflex has a normal initial response that decreases progressively with time. As a consequence of the time-dependent response, the cardiopulmonary reflex response should be measured over small intervals of time in clinical studies.

Pressure and time dependence of the cardiopulmonary reflex response in patients with hypertensive cardiomyopathy

The first minutes of the time course of cardiopulmonary reflex control evoked by lower body negative pressure (LBNP) in patients with hypertensive cardiomyopathy have not been investigated in detail. We studied 15 hypertensive patients with left ventricular dysfunction (LVD) and 15 matched normal controls to observe the time course response of the forearm vascular resistance (FVR) during 3 min of LBNP at -10, -15, and -40 mmHg in unloading the cardiopulmonary receptors. Analysis of the average of 3-min intervals of FVR showed a blunted response of the LVD patients at -10 mmHg (P = 0.03), but a similar response in both groups at -15 and -40 mmHg. However, using a minute-to-minute analysis of the FVR at -15 and -40 mmHg, we observed a similar response in both groups at the 1st min, but a marked decrease of FVR in the LVD group at the 3rd min of LBNP at -15 mmHg (P = 0.017), and -40 mmHg (P = 0.004). Plasma norepinephrine levels were analyzed as another neurohumoral measurement of cardiopulmonary receptor response to LBNP, and showed a blunted response in the LVD group at -10 (P = 0.013), -15 (P = 0.032) and -40 mmHg (P = 0.004). We concluded that the cardiopulmonary reflex response in patients with hypertensive cardiomyopathy is blunted at lower levels of LBNP. However, at higher levels, the cardiopulmonary reflex has a normal initial response that decreases progressively with time. As a consequence of the time-dependent response, the cardiopulmonary reflex response should be measured over small intervals of time in clinical studies.

[Efficacy of decompression treatment of abdominal compartment syndrome]. / Eficacia del tratamiento descompresivo en el síndrome del compartimiento abdominal.

INTRODUCTION: Abdominal compartment syndrome (ACS) is an entity that represents a latent problem in the patient subjected to laparotomy. OBJECTIVE: To evaluate the effectiveness of decompressive treatment of ACS. MATERIAL AND METHODS: We studied patients subjected to decompressive treatment for diagnosis of SCA from May 1 to November 30, 2001 prospectively. We evaluated intraabdominal pressure (IAP), peak pressure of air way (J)PVA), oxygen available index (OAi), ventilation-perfussion index and uresis, before, after, and at 48 h of decompressive surgery. The data were treated statistically with paired student t test taking as significant p < 0.05 using percentages for qualitative variables and average with standard deviation for quantitative variables. RESULTS: We included 10 patients; three died (30%). Alone it VP & it descended significantly after compression (1 > < 0.05). Uresis, PPVA, OlA and VPI were carried out 48 h of decompressive surgery. CONCLUSIONS: Decompressive treatment is effective in ACS, showing immediate decreased of IAP and improvement of the hemodynamic variables after 48 h post-surgery.

Mejoría de las pruebas de función respiratoria por paracentesis en pacientes con ascitis a tensión / Improvement in functional respiratory tests in patients with tense ascites

La ascitis a tensión ocasiona insuficiencia respiratoria mecánica al dificultar el descenso del diafragma; la paracentesis evacuadora debe mejorar este cuadro. El objetivo del trabajo fue determinar el efecto de la paracentesis evacuadora sobre las pruebas de función respiratoria en el enfermo con ascitis a tensión. En un grupo de 15 sujetos con ascitis a tensión (secundaria a cirrosis hepática) que provocó dificultad respiratoria se realizaron gasometría arterial, medición del perímetro abdominal y pruebas de función respiratoria previa y posteriormente (dos y 24 h) a la realización de paracentesis evacuadora de tres litros de líquido de ascitis. En ninguno de los casos el paciente se encontraban en encefalopatía hepática o sangrado de tubo digestivo alto. El método estadístico empleado fue t de Student. En los 15 sujetos hubo disminución del perímetro abdominal de 3 cm en promedio, así como resolución de los síntomas respiratorios. En la gasometría arterial hubo elevación de paO2, en promedio 5 mmHg (p< 0.005), la saturación de O2 mejoró 2.61 por ciento (p< 0.05). En las pruebas de función respiratoria todos los sujetos mostraron un patrón obstuctivo. La velocidad máxima de flujo a la exhalación (VMFE) mejoró en promedio 0.2 y 0.4 l/seg a las dos y 24 h (p < 0.001), la capacidad vital forzada (CVF) disminuyó 0.36 y 0.25 l respectivamente (p < 0.5 en ambos valores), el volumen espiratorio forzado del primer segundo (VEF1) subió 0.01 y 0.4 l (p< 0.05 y < 0.005), y la relación CVE/VEF1 se elevó 8.7 y 13 por ciento (p< 0.05 y < 0.005). Característicamente los pacientes que obtuvieron un menor beneficio de la paracentesis eran fumadores. La paracentesis es un método eficaz para mejorar la función respiratoria del sujeto con ascitis a tensión

Tolerance to lower body negative pressure exposure: comparison between patients with neurocardiogenic syncope and controls.

Lower body negative pressure exposure (LBNPE) produces hemodynamic modifications similar to those produced by head-up tilt test (HUT). Patients with vasovagal syncope are more susceptible to HUT than healthy persons. The supine position during LBNPE would facilitate the simultaneous performance of complementary methods. The aim of this study was to compare tolerance to LBNPE between a group of patients with vasovagal syncope and a group of healthy volunteers. Eleven patients with vasovagal syncope and positive HUT and 13 healthy volunteers without prior history of syncope and negative HUT were included. The following protocol was used: -10 mmHg, 1 minute; -20 mmHg, 1 minute; -30 mmHg, 3 minutes, and -40, -50, -60, and -70 mmHg, 5 minutes for each stage. Tolerance was expressed as: maximum tolerated negative pressure (Max NP), maximum tolerated time (Max T), and sigma P x T, where P = pressure and T = time. Syncope or presyncope during the test was considered positive LBNPE. LBNPE was positive at -50 or -60 mmHg in 8 of 11 patients (73%). One healthy volunteer had presyncope after 5 minutes at -70 mmHg. Tolerance, as expressed by any of the three parameters, was significantly higher for the healthy volunteers (Max NP: -59.1 +/- 7.9 vs -70, P < 0.01; Max T: 19.1 +/- 4.2 vs 24.4 +/- 0.3, P < 0.01; sigma P x T: 836.3 +/- 269.5 vs 1214.6 +/- 18, P < 0.01). We conclude that patients with neurocardiogenic syncope have a significantly lower tolerance to LBNPE than subjects with no previous history of syncope.

Evaluation of the routine use of the nasogastric tube in digestive operation by a prospective controlled study.

This prospective, randomized controlled trial was undertaken to evaluate the effect of tube decompression of the stomach after surgical procedure on the digestive tract. One hundred and nine patients were randomly allocated to postoperative treatment with (57 patients) or without (52 patients) nasogastric tubes. No significant differences were found between the two groups in the duration of hospitalization, time to begin peroral fluid intake, occurrence of hiccups, vomiting, nausea, parotiditis, nasal septum necrosis, anastomotic leak and wound dehiscence. Moreover, abdominal distension, pyrosis, otalgia, dysphagia, odynophagia and atelectasis occurred more often in intubated patients as shown by chi-square analysis of the data with Yates correction, with the level of significance at p = less than 0.05. Tube decompression of the stomach does not relieve intestinal paralysis after digestive operations. These data seem to indicate that the routine prophylactic use of a nasogastric tube is unnecessary in gastrointestinal operations.