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Patient survival from biventricular thrombosis is possible using mechanical support followed by cardiac transplantation.
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Extracorporeal membrane oxygenation has been extensively used for cardiopulmonary support in cardiogenic shock. However, its clinical value in the management of pheochromocytoma crisis remains unclear. We report a rare case of life-threatening cardiogenic shock managed with peripheral venoarterial extracorporeal membrane oxygenation combined with endovascular left ventricular venting, in a 40-year-old female patient, in the setting of unknown adrenal pheochromocytoma. We highlight the life-saving role of extracorporeal membrane oxygenation in undiagnosed endocrine emergencies, allowing cardiac and end-organ recovery, and giving time for accurate diagnosis and specific treatment in such unusual situations.
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Neoplasias das Glândulas Suprarrenais/complicações , Oxigenação por Membrana Extracorpórea , Feocromocitoma/complicações , Choque Cardiogênico/terapia , Neoplasias das Glândulas Suprarrenais/diagnóstico por imagem , Neoplasias das Glândulas Suprarrenais/patologia , Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia , Adulto , Emergências , Feminino , Humanos , Feocromocitoma/diagnóstico por imagem , Feocromocitoma/patologia , Feocromocitoma/cirurgia , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Portal venous flow pulsatility detected by Doppler ultrasound is a sign of congestive heart failure in noncritically ill patients. The assessment of portal and splenic venous flows has never been reported in patients undergoing cardiac surgery. METHODS: This is a case series performed in patients undergoing cardiac surgery between February 2014 and February 2015 in which portal and/or splenic venous flows were assessed by the attending anesthesiologist during surgery or by the intensivist after surgery using transthoracic echography in 9 patients or transesophageal echocardiography in 5 patients. Data collection was done retrospectively by reviewing intraoperative and postoperative monitoring documents. The technique of assessment is detailed in this article. RESULTS: We report the abnormal portal and/or splenic venous flow pulsatility from 14 patients perioperatively. At the time of pulsatility detection, patients had a median cumulative fluid balance of 3.8 L (interquartile range: 0-4.6 L) and a median right atrial pressure of 14.0 mm Hg (interquartile range: 12.0-15.5 mm Hg). In some patients (4/14), signs of right ventricular dysfunction on echocardiography and/or right ventricular pressure monitoring were present. CONCLUSIONS: Doppler evaluation of portal and splenic venous flow using transthoracic echography and transesophageal echocardiography may represent a promising modality to assess end-organ venous congestion in cardiac surgery patients.
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Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hipertensão Portal/diagnóstico por imagem , Testes Imediatos , Complicações Pós-Operatórias/diagnóstico por imagem , Ultrassonografia Doppler/métodos , Idoso , Velocidade do Fluxo Sanguíneo/fisiologia , Feminino , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos RetrospectivosRESUMO
PURPOSE: Vascular access care is a key topic for hemodialysis patients. The most cost-effective and lasting vascular access for chronic hemodialysis is the native arteriovenous fistula (AVF); however, bleeding after dialysis session from puncture site is a relevant problem. Achieving hemostasis is necessary and requires hand compression by the nurse or the patient if he or she is capable and cooperative. METHODS: We assessed a new vascular closure device, VITACLIP® (Serumwerk Bernburg Vertriebs GmbH) that is an adhesive silicone seal device, which can be set onto the skin and punctured by dialysis needle. After withdrawal of the needle, VITACLIP® prevents bleeding from the punctured vessels, making hand compression unnecessary. RESULTS: We used this device in 5 chronic hemodialysis patients with native lateral-terminal AVFs. The patients' hemodialysis prescription and anticoagulants dose were not changed. This device allowed puncture of vascular access without complications such as bleeding at the end of hemodialysis; we did not observe any mechanical complications due to needle dislocation or any dermatological lesions at skin puncture site. However, the cannulation proved to be more difficult for the nurses with this device because the silicone hampers identification of the vessel for puncture for deeper AVFs. CONCLUSIONS: This device helps patient management and improves patient safety by reducing the risk of AVF bleeding at the end of dialysis, decreasing the risk of staff contact with patients' blood, and theoretically eliminating the risk of massive bleeding in the case of an inadvertent needle dislodgement going unnoticed during treatment.
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Derivação Arteriovenosa Cirúrgica , Hemorragia/prevenção & controle , Técnicas Hemostáticas/instrumentação , Diálise Renal , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/instrumentação , Derivação Arteriovenosa Cirúrgica/enfermagem , Atitude do Pessoal de Saúde , Desenho de Equipamento , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Hemorragia/etiologia , Técnicas Hemostáticas/efeitos adversos , Técnicas Hemostáticas/enfermagem , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Agulhas , Projetos Piloto , Punções , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
The elderly are at high risk for acute kidney injury (AKI). With the aging of the population, the demand for intensive care unit (ICU) admission from older patients will continue to rise, and this clinical entity will likely become increasingly common. In this article we review the relevant literature, discuss the age-related changes that render older people prone to AKI development, and examine the most frequent etiologies for renal impairment in these patients. We also consider the difficulties in achieving an early diagnosis in the elderly ICU patient, the particularities related to AKI treatment in this age group, and the data available on differences in renal recovery and mortality between the young and the old with renal injury. More importantly, we highlight the methods for prevention of AKI development or worsening in the elderly critically ill patient.
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Injúria Renal Aguda/mortalidade , Estado Terminal/mortalidade , Unidades de Terapia Intensiva/organização & administração , Admissão do Paciente/estatística & dados numéricos , Injúria Renal Aguda/terapia , Idoso , Estado Terminal/terapia , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Testes de Função Renal , Diálise Renal/mortalidade , Medição de Risco/estatística & dados numéricosRESUMO
INTRODUCTION: Oxidative stress (OS) is an imbalance between the production of oxidizing chemical species and the antioxidant defense. It is known that OS increases in critically ill patients with acute kidney injury (AKI). Measurement of advanced oxidation protein products (AOPPs) has been found to be a simple tool for monitoring OS. AIMS: The aims of this study were to evaluate OS in intensive care unit (ICU) patients by AOPP levels and compare its levels between patients with and without AKI; we also wanted to assess the ability of AOPP to predict the development of AKI in this population. PATIENTS, MATERIAL, AND METHODS: We performed a prospective cohort study to compare AOPP levels between critically ill AKI (as defined by Risk-Injury-Failure-Loss-End Stage Renal Disease [RIFLE] criteria) and non-AKI patients. Blood samples were collected from all consecutively admitted patients upon arrival to ICU and daily for up to 4 days. We collected 234 blood samples from 86 adult medical and surgical ICU patients. The levels of AOPP were determined in the plasma and measured by spectrophotometry at 340 nm and compared between non-AKI (n = 71) and AKI patients (n = 15). We further subdivided the AKI patients according to severity of AKI (worst RIFLE class attained in ICU). RESULTS: Among the 86 patients, 15 (17.44%) developed AKI during their stay in ICU, whereas 71 patients (82.56%) did not. Among the AKI patients, 5 had AKI on ICU admission, whereas 10 developed it later. The levels of AOPP were significantly higher among AKI patients compared with non-AKI patients (153.8 ± 117.8 versus 129.0 ± 114.9 µmol/L, respectively; P = .034). Patients with the most severe AKI (RIFLE class Failure) had markedly elevated AOPP levels compared with RIFLE class Risk and Injury patients (P = .012). Area under the curve of receiver operating characteristic for prediction of AKI within 48 hours after first blood sample collection was 0.5835 (P = not significant). CONCLUSIONS: This is the first study to explore the relationship between severity of AKI and AOPP. In our adult ICU population, AOPP levels were higher in AKI compared with non-AKI critically ill patients. On the other hand, AOPP levels were not found to be a useful biomarker for AKI, as it was unable to identify patients who developed AKI within 24, 48, 76, and 96 hours.
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Injúria Renal Aguda/sangue , Proteínas Sanguíneas/análise , Estresse Oxidativo , Adulto , Idoso , Biomarcadores/sangue , Estado Terminal , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Oxirredução , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
Extracorporeal therapies are able to sustain life through different mechanisms. This approach, called multiple organ support therapy, can in fact obtain blood purification by hemodialysis/hemofiltration to replace kidney function, temperature control, electrolyte and acid-base control to mimic homeostatic regulation of the kidney and circulation, fluid balance control to support the right hydration and cardiac performance, cardiac support removing cardiodepressant substances and equilibrating potassium levels, blood detoxification and liver support by coupled plasma filtration and adsorption or direct adsorption on blood (hemoperfusion), immunomodulation and endothelial support in the presence of sepsis by cutting the peaks of pro- and anti-inflammatory mediators, and immunoadsorption or adsorption of specific substances such as endotoxin. A missing piece of this group of therapies was the protective lung support. Today this is made possible by removal of CO(2) either by complete extracorporeal membrane oxygenation or by using decapneization in conjunction with hemofiltration in a system called DECAP/DECAPSMART. In conclusion, circulating blood outside the body and treating it with different filters or cartridges in a multiple organ support therapy may represent an important support for multiple organ dysfunction conditions induced by sepsis, acute respiratory distress syndrome and in recent times by complicated H1N1-related infections.
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Dióxido de Carbono/isolamento & purificação , Hemofiltração/métodos , Pulmão/fisiopatologia , Insuficiência de Múltiplos Órgãos/terapia , Terapia de Substituição Renal/métodos , Respiração Artificial/métodos , Estado Terminal/terapia , Oxigenação por Membrana Extracorpórea/métodos , Hemoperfusão/métodos , Humanos , Hipodermóclise/métodos , Vírus da Influenza A Subtipo H1N1 , Influenza Humana/complicações , Influenza Humana/prevenção & controle , Síndrome do Desconforto Respiratório/terapiaRESUMO
The risk of developing acute kidney injury (AKI) is significantly increased in the elderly. It is the age-related renal and systemic changes as well as frequent comorbidities that render older individuals greatly susceptible to acute renal impairment. Although most often multifactorial, specific etiologies such as renal hypoperfusion due to cardiac failure, dehydration or hypotension of any cause, as well as sepsis, drug toxicity, surgery, or obstructive causes are often present. Contrast-induced nephropathy and atheroembolic disease are also frequently seen, especially in an acute care setting. Serum creatinine is most commonly used for diagnosis, despite it having several limitations, especially in the elderly. The mainstay of management is prevention of further deterioration, as the chances of renal recovery may be lower in older patients.
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Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/complicações , Injúria Renal Aguda/prevenção & controle , Injúria Renal Aguda/terapia , Idoso , Envelhecimento/fisiologia , Comorbidade , Desidratação/complicações , Cardiopatias/complicações , Cardiopatias/epidemiologia , Insuficiência Cardíaca/complicações , Hemorragia/complicações , Humanos , Hipotensão/complicações , Rim/crescimento & desenvolvimento , Rim/fisiopatologia , Túbulos Renais/crescimento & desenvolvimento , Túbulos Renais/patologia , Preparações Farmacêuticas/metabolismo , Terapia de Substituição Renal , Vasoconstrição/fisiologiaRESUMO
Acute kidney injury (AKI) is becoming increasingly common in elderly individuals. The presence of multiple comorbidities as well as age-related changes in the kidney, systemic vasculature and immunological system render older patients more prone to renal injury. Hypovolemia, sepsis, and iatrogenic complications related to drug toxicity, contrast-induced nephropathy, and perioperative complications therefore often occur in older hospitalized patients. Although AKI is treated in the same way in elderly individuals and younger patients, elderly individuals are more vulnerable to dialysis-related complications such as hemodynamic instability, bleeding, and mild disequilibrium syndrome. Strategies for the prevention of AKI are particularly important in these fragile patients, but making an early diagnosis is especially challenging in this age group.