RESUMO
OBJECTIVE: To compare the respective effects of established measures used for management of traumatic brain injury (TBI) patients on cerebral blood flow (CBF) and cerebral metabolic rates of oxygen (CMRO2), glucose (CMRGlc) and lactate (CMRLct). METHODS: Thirty-six patients suffering from severe traumatic brain injury (TBI) were prospectively evaluated. In all patients baseline assessments were compared with that following moderate hyperventilation (reducing PaCO2 from 36 +/- 4 to 32 +/- 4 mmHg) and with that produced by administration of 0.5 gr/kg mannitol 20% intravenously. Intracranial and cerebral perfusion pressure (ICP, CPP), CBF and arterial jugular differences in oxygen, glucose and lactate contents were measured for calculation of CMRO2, CMRGlc and CMRLct. RESULTS: Following hyperventilation, CBF was significantly reduced (P < 0.0001). CBF remained most often above the ischemic range although values less than 30 ml x 100 gr(-1) x min(-1) were found in 27.8% of patients. CBF reduction was associated with concurrent decrease in CMRO2, anaerobic hyperglycolysis and subsequent lactate production. In contrast, mannitol resulted in significant albeit moderate improvement of cerebral perfusion. However, administration of mannitol had no ostensible effect either on oxidative or glucose metabolism and lactate balance remained mostly unaffected. CONCLUSIONS: Moderate hyperventilation may exacerbate pre-existing impairment of cerebral blood flow and metabolism in TBI patients and should be therefore carefully used under appropriate monitoring. Our findings rather support the use of mannitol for ICP control.
Assuntos
Edema Encefálico/terapia , Lesões Encefálicas/complicações , Circulação Cerebrovascular/efeitos dos fármacos , Hiperventilação/metabolismo , Hipertensão Intracraniana/terapia , Manitol/uso terapêutico , Adolescente , Adulto , Idoso , Edema Encefálico/etiologia , Edema Encefálico/fisiopatologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/terapia , Córtex Cerebral/efeitos dos fármacos , Córtex Cerebral/metabolismo , Córtex Cerebral/fisiopatologia , Diuréticos Osmóticos/uso terapêutico , Feminino , Glucose/metabolismo , Glicólise/efeitos dos fármacos , Glicólise/fisiologia , Humanos , Hipertensão Intracraniana/etiologia , Hipertensão Intracraniana/fisiopatologia , Ácido Láctico/metabolismo , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio/efeitos dos fármacos , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/normas , Resultado do TratamentoRESUMO
A case report of a patient with acute myocardial infarction and severe hypoxemia due to acute right to left interatrial shunt (RLIAS) is presented. Diagnostic and therapeutic procedures are discussed.
Assuntos
Hipóxia/etiologia , Infarto do Miocárdio/etiologia , Idoso , Oclusão com Balão , Implante de Prótese Vascular , Angiografia Coronária , Doença das Coronárias/diagnóstico , Doença das Coronárias/terapia , Ecocardiografia , Ecocardiografia Transesofagiana , Comunicação Interatrial/diagnóstico , Comunicação Interatrial/terapia , Humanos , Hipóxia/diagnóstico , Hipóxia/terapia , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Índice de Gravidade de Doença , Stents , Disfunção Ventricular Direita/diagnóstico , Disfunção Ventricular Direita/terapiaRESUMO
The morbidity and mortality from sepsis and multiple organ dysfunction syndrome (MODS) continues to be high. An increase in FcgammaRI+ (CD64+) monocytes was demonstrated in septic patients, and an association between cell number, their secretory activity, and poor outcome has been described. In the present investigation further characterization of CD64+ leukocytes has been attempted. The study was aimed at examining the phagocytic activity (PA) and reactive oxygen species (ROS) production by monocytes (Mo) and neutrophils (Neu) in sepsis and sepsis-induced acute respiratory distress syndrome (ARDS) related to the pattern of CD64 expression. Twenty-three post-traumatic or post-operative male and female patients with sepsis were enrolled. The control group consisted of 10 healthy volunteers. Arterial blood samples were taken during the septic episode for flow cytometric analysis of surface leukocyte antigens, phagocytosis, and ROS production. CD64 expression on Mo and Neu was markedly increased in septic patients (P = 0.029 and P = 0.0005), and even more in sepsis with ARDS (P = 0.011). In healthy individuals, PA of CD64+ Neu was higher, than of CD64- cells (P = 0.021). In septic patients, decreased PA was detected in CD64+ Mo and Neu (P = 0.013 and P = 0.040, respectively). CD64+ Neu of patients in ARDS exhibited the most prominent PA depression (P = 0.048). ROS production in non-separated Mo and Neu was increased in sepsis (P = 0.026 and P = 0.004, respectively). In healthy individuals CD64+ Neu and stimulated CD64+ Mo demonstrated increased ROS synthesis compared to matched CD64- cells (P = 0.001 and P = 0.042, respectively). Although ROS production by CD64+ leukocytes in sepsis was also increased compared to CD64- cells, significantly less ROS was generated compared to healthy subjects (P = 0.021). In conclusion, overexpression of CD64 on blood Mo and Neu from patients with sepsis and ARDS is associated with depressed PA and decreased oxidative response.