COVID-19-associated acute kidney injury patients treated with renal replacement therapy in the intensive care unit: A multicenter study in São Paulo, Brazil.

INTRODUCTION: Multicenter studies involving patients with acute kidney injury (AKI) associated with the disease caused by the new coronavirus (COVID-19) and treated with renal replacement therapy (RRT) in developing countries are scarce. The objectives of this study were to evaluate the demographic profile, clinical picture, risk factors for mortality, and outcomes of critically ill patients with AKI requiring dialysis (AKI-RRT) and with COVID-19 in the megalopolis of São Paulo, Brazil. METHODS: This multicenter, retrospective, observational study was conducted in the intensive care units of 13 public and private hospitals in the metropolitan region of the municipality of São Paulo. Patients hospitalized in an intensive care unit, aged ≥ 18 years, and treated with RRT due to COVID-19-associated AKI were included. RESULTS: The study group consisted of 375 patients (age 64.1 years, 68.8% male). Most (62.1%) had two or more comorbidities: 68.8%, arterial hypertension; 45.3%, diabetes; 36.3%, anemia; 30.9%, obesity; 18.7%, chronic kidney disease; 15.7%, coronary artery disease; 10.4%, heart failure; and 8.5%, chronic obstructive pulmonary disease. Death occurred in 72.5% of the study population (272 patients). Among the 103 survivors, 22.3% (23 patients) were discharged on RRT. In a multiple regression analysis, the independent factors associated with death were the number of organ dysfunctions at admission and RRT efficiency. CONCLUSION: AKI-RRT associated with COVID-19 occurred in patients with an elevated burden of comorbidities and was associated with high mortality (72.5%). The number of organ dysfunctions during hospitalization and RRT efficiency were independent factors associated with mortality. A meaningful portion of survivors was discharged while dependent on RRT (22.3%).

COVID-19-associated acute kidney injury patients treated with renal replacement therapy in the intensive care unit: A multicenter study in São Paulo, Brazil

INTRODUCTION: Multicenter studies involving patients with acute kidney injury (AKI) associated with the disease caused by the new coronavirus (COVID-19) and treated with renal replacement therapy (RRT) in developing countries are scarce. The objectives of this study were to evaluate the demographic profile, clinical picture, risk factors for mortality, and outcomes of critically ill patients with AKI requiring dialysis (AKI-RRT) and with COVID-19 in the megalopolis of São Paulo, Brazil. METHODS: This multicenter, retrospective, observational study was conducted in the intensive care units of 13 public and private hospitals in the metropolitan region of the municipality of São Paulo. Patients hospitalized in an intensive care unit, aged ≥ 18 years, and treated with RRT due to COVID-19-associated AKI were included. RESULTS: The study group consisted of 375 patients (age 64.1 years, 68.8% male). Most (62.1%) had two or more comorbidities: 68.8%, arterial hypertension; 45.3%, diabetes; 36.3%, anemia; 30.9%, obesity; 18.7%, chronic kidney disease; 15.7%, coronary artery disease; 10.4%, heart failure; and 8.5%, chronic obstructive pulmonary disease. Death occurred in 72.5% of the study population (272 patients). Among the 103 survivors, 22.3% (23 patients) were discharged on RRT. In a multiple regression analysis, the independent factors associated with death were the number of organ dysfunctions at admission and RRT efficiency. CONCLUSION: AKI-RRT associated with COVID-19 occurred in patients with an elevated burden of comorbidities and was associated with high mortality (72.5%). The number of organ dysfunctions during hospitalization and RRT efficiency were independent factors associated with mortality. A meaningful portion of survivors was discharged while dependent on RRT (22.3%).

Utilização do FAST-Estendido (EFAST-Extended Focused Assessment with Sonography for Trauma) em terapia intensiva / Usefulness of Extended-FAST (EFAST-Extended Focused Assessment with Sonography for Trauma) in critical care setting

A principal causa de morte no Brasil, em pacientes com idade inferior a 45 anos, está relacionada ao trauma, sendo responsável por um terço das internações em unidades de terapia intensiva. Em virtude do crescente conhecimento e disponibilidade da ultrassonografia para o diagnóstico e monitoramento de lesões ameaçadoras à vida, como tamponamento cardíaco e ruptura de órgão sólido na cavidade abdominal com choque hemorrágico, foi desenvolvido um protocolo denominado FAST (Focused Assesment with Sonography for Trauma) no ambiente de emergência e terapia intensiva. Esta tecnologia está ganhando adeptos por sua reprodutibilidade, ausência de exposição à radiação ao paciente e facilidade beira leito. Uma nova complementação a este protocolo, denominada FAST-Estendido, proporciona informações valiosas na condução desses pacientes, ampliando o diagnóstico de doenças antes reservadas à cavidade abdominal e pericárdica, conjuntamente com doenças localizadas na cavidade torácica, em busca de hemotórax, derrame pleural e pneumotórax. Devemos salientar que esta modalidade de exame complementar substitui a tomografia computadorizada e o lavado peritoneal diagnóstico, mas não o retardo de intervenções cirúrgicas. Sua avaliação criteriosa, conjuntamente com dados clínicos, deve nortear as condutas terapêuticas, principalmente em locais inóspitos e/ou com limitações de recursos, como pré-hospitalar, unidades de terapia intensiva em zonas de conflito armado, áreas rurais e/ou geograficamente distantes, nas quais não há disponibilidade de outros métodos de imagem.

Trauma is the leading cause of death in people below 45 years-old in Brazil, and responsible for one third of all intensive care unit admissions. The increasing knowledge on ultrasound diagnosis methods and its availability for life-threatening injuries (such as cardiac tamponade and abdominal cavity solid organs rupture leading to hemorrhagic shock) diagnosis and monitoring, lead to the development o the FAST (Focused Assessment with Sonography for Trauma) protocol, aimed to be used both in the emergency and intensive care unit settings. Due to its reproducibility, lack of radiation exposure, and bedside feasibility, this technology is being increasingly accepted. A new protocol extension, the Extended-FAST, provides valuable information for improved patients' management, extending its availability from the abdominal conditions to other diagnosis such as hemothorax, pleural effusion and pneumothorax. We must underline that this technique is able to replace computed tomography and diagnostic peritoneal wash, and do not delay surgical procedure instead of perform this exam . Thus, its careful appraisal in connection with the clinical information should guide the therapeutic approaches, specially in inhospitable sites such as intensive care units in war zones, rural or distant places, were other imagery methods are not available.

Novas evidências em antitrombóticos na fibrilação atrial 2010 / New evidences in antithrombotics for atrial fibrillation 2010

JUSTIFICATIVA E OBJETIVOS: A principal arritmia cardíaca em pacientes acima dos 60 anos de idade é a fibrilação atrial (FA). Com o aumento da expectativa de vida, estima-se que 30% da população acima de 65 anos, apresentará FA, e esta é associada a um risco de eventos cardio embólicos anuais ao redor de 6% ao ano. Devido as complicações cardio embólicas, o tratamento de eleição é o uso de fármacos antitrombóticos, os quais estão incluídos, os antiplaquetários e os anticoagulantes, baseados na estratificação de risco do paciente. Até o momento, a terapia de eleição na prevenção de eventos cardio embólicos são os antagonistas de vitamina K (AVK); entretanto, devido sua janela terapêutica estreita, controle laboratorial rigoroso, interação com outros medicamentos e principalmente dificuldade de utilização em pacientes idosos, torna-se um fator limitador na prática clínica diária. Dentro deste cenário, novos antitrombóticos estão sendo desenvolvidos no intuito de melhorar o cuidado e a qualidade de vida dos portadores de FA e talvez substituir os AVK. CONTEÚDO Artigos publicados entre 1969 e 2009 foram selecionados no banco de publicações Medline, através das palavras-chaves fibrilação atrial, antitrombóticos, anticoagulantes e antiplaquetários, assim como diretrizes internacionais foram buscadas no link http://sumsearch.uthscsa.edu. CONCLUSÃO: O desenvolvimento de novos antitrombóticos, através de ensaios clínicos aleatórios, talvez em um futuro próximo possibilite a utilização e implementação de forma sistemática na pratica clinica destes novos medicamentos, como, por exemplo, os inibidores diretos da trombina, inibidores diretos e indiretos do fator Xa, superando as limitações dos AVK.(AU)

BACKGROUND AND OBJECTIVES: The main cardiac arrhythmia in patients over 60 years of age is atrial fibrillation (AF). With increasing life expectancy, it is estimated that 30% of the population over 65 years, will present FA, and this is associated with a risk of cardioembolic events annually around 6% per annum. Because of cardioembolic complications, the treatment of choice is the use of antithrombotic drugs, which are included, the antiplatelet agents and anticoagulants, based on risk stratification of patients. So far, the therapy of choice in the prevention of cardioembolic events are antagonists of vitamin K (AVK), however, due to its narrow therapeutic window, under strict control, interaction with other drugs and especially difficult to use in elderly patients, it is a limiting factor in clinical practice. Within this scenario, new antithrombotic agents are being developed in order to improve care and quality of life of patients with AF and perhaps replace the AVK. The development of new antithrombotic drugs through clinical trials, perhaps in the near future allow the use and implementation in a systematic manner in the clinical practice of these new drugs, such as the direct thrombin inhibitors, indirect and direct inhibitors of factor Xa, overcoming limitations of AVK.CONTENTS: Articles published from 1969 to 2009 were selected in the MedLine database, using the keywords Atrial Fibrillation, antithrombotics, anticoagulants, antiplatelets in the MedLine database as well as search for international guidelines in http://sumsearch.uthscsa.edu.CONCLUSION: The development of new antithrombotic drugs through clinical trials, perhaps in the near future allow the use and implementation in a systematic manner in the clinical practice of these new drugs, such as the direct thrombin inhibitors, indirect and direct inhibitors of factor Xa, overcoming limitations of AVK.(AU)

Usefulness of Extended-FAST (EFAST-Extended Focused Assessment with Sonography for Trauma) in critical care setting. / Utilização do FAST-Estendido (EFAST-Extended Focused Assessment with Sonography for Trauma) em terapia intensiva.

Trauma is the leading cause of death in people below 45 years-old in Brazil, and responsible for one third of all intensive care unit admissions. The increasing knowledge on ultrasound diagnosis methods and its availability for life-threatening injuries (such as cardiac tamponade and abdominal cavity solid organs rupture leading to hemorrhagic shock) diagnosis and monitoring, lead to the development o the FAST (Focused Assessment with Sonography for Trauma) protocol, aimed to be used both in the emergency and intensive care unit settings. Due to its reproducibility, lack of radiation exposure, and bedside feasibility, this technology is being increasingly accepted. A new protocol extension, the Extended-FAST, provides valuable information for improved patients' management, extending its availability from the abdominal conditions to other diagnosis such as hemothorax, pleural effusion and pneumothorax. We must underline that this technique is able to replace computed tomography and diagnostic peritoneal wash, and do not delay surgical procedure instead of perform this exam . Thus, its careful appraisal in connection with the clinical information should guide the therapeutic approaches, specially in inhospitable sites such as intensive care units in war zones, rural or distant places, were other imagery methods are not available.

Cuidados com o potencial doador de orgãos / Cares with the potential donor of organs

O período entre o diagnóstico de morte encefálica (ME) e a retirada de órgãos para transplante é caracterizada por uma série de alterações cardiorrespiratórias, hormonais e eletrolíticas, que se não tratadas prontamente acarretam perda da viabilidade dos órgãos para um possível receptor...