Vasopressin Versus Norepinephrine for the Management of Septic Shock in Cancer Patients: The VANCS II Randomized Clinical Trial.

OBJECTIVES: Previous trials suggest that vasopressin may improve outcomes in patients with vasodilatory shock. The aim of this study was to evaluate whether vasopressin could be superior to norepinephrine to improve outcomes in cancer patients with septic shock. DESIGN: Single-center, randomized, double-blind clinical trial, and meta-analysis of randomized trials. SETTING: ICU of a tertiary care hospital. PATIENTS: Two-hundred fifty patients 18 years old or older with cancer and septic shock. INTERVENTIONS: Patients were assigned to either vasopressin or norepinephrine as first-line vasopressor therapy. An updated meta-analysis was also conducted including randomized trials published until October 2018. MEASUREMENTS AND MAIN RESULTS: The primary outcome was all-cause mortality at 28 days after randomization. Prespecified secondary outcomes included 90-days all-cause mortality rate; number of days alive and free of advanced organ support at day 28; and Sequential Organ Failure Assessment score 24 hours and 96 hours after randomization. We also measure the prevalence of adverse effects in 28 days. A total of 250 patients were randomized. The primary outcome was observed in 71 patients (56.8%) in the vasopressin group and 66 patients (52.8%) in the norepinephrine group (p = 0.52). There were no significant differences in 90-day mortality (90 patients [72.0%] and 94 patients [75.2%], respectively; p = 0.56), number of days alive and free of advanced organ support, adverse events, or Sequential Organ Failure Assessment score. CONCLUSIONS: In cancer patients with septic shock, vasopressin as first-line vasopressor therapy was not superior to norepinephrine in reducing 28-day mortality rate.

Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial.

BACKGROUND: Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. METHODS: This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min · m) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 µg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. RESULTS: A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. CONCLUSIONS: The authors' results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.

Denervação simpática cirúrgica para o controle de tempestade arrítmica e choques repetidos de desfibrilador implantável em criança com síndrome do QT longo congênito / Sympathetic denervation surgery to control of arrhythmic storm and repeated chocks with the implantable defibrillator in children with congenital long QT syndrome

Relata-se o caso de uma criança com síndrome do QT longo congênito e Tetralogia de Fallot, submetidaa denervação simpática por videotoracoscopia, para controle de tempestades arrítmicas e diminuição do númerode choques do cardioversor-desfibrilador implantável...

We report the case of a child with congenital long QT syndrome and Tetralogy of Fallot submittedto sympathetic denervation by videolaparoscopy to control arrhythmic storms and decrease the number ofimplantable cardioversor-defibrillator chocks...

Effectiveness of epicardial atrial pacing using a bipolar steroid-eluting endocardial lead with active fixation in an experimental model.

PURPOSE: To assess the effectiveness of bipolar epicardial atrial pacing using an active fixation bipolar endocardial lead implanted on the atrial surface in an experimental model. METHODS: A total of ten Large White adult pigs underwent pacemaker implantation under general anesthesia. Atrial pacing and sensing parameters were obtained at the procedure, immediate postoperative period and on the 7th and the 30th postoperative in unipolar and bipolar configurations. RESULTS: All procedures were successfully performed. There were no perioperative complications and no early deaths. Atrial pacing and sensing parameters for both unipolar and bipolar modes remained stable throughout the study. We observed a progressive increase in atrial thresholds, ranging from 0.49 ± 0.35 (at implantation) to 1.86 ± 1.31 volts (30th postoperative day), in unipolar mode. Atrial impedance measurements decreased slightly over time, ranging from 486.80 ± 126.35 Ohms (at implantation) to 385.0 ± 80.52 Ohms (30th postoperative day). Atrial sensing measures remained stable from the immediate postoperative period until the end of the study. CONCLUSION: The bipolar active fixation endocardial lead implanted epicardially can provide stable conditions of pacing and sensing parameters throughout the postoperative follow-up.

Effectiveness of epicardial atrial pacing using a bipolar steroid-eluting endocardial lead with active fixation in an experimental model

PURPOSE: To assess the effectiveness of bipolar epicardial atrial pacing using an active fixation bipolar endocardial lead implanted on the atrial surface in an experimental model. METHODS: A total of ten Large White adult pigs underwent pacemaker implantation under general anesthesia. Atrial pacing and sensing parameters were obtained at the procedure, immediate postoperative period and on the 7th and the 30th postoperative in unipolar and bipolar configurations. RESULTS: All procedures were successfully performed. There were no perioperative complications and no early deaths. Atrial pacing and sensing parameters for both unipolar and bipolar modes remained stable throughout the study. We observed a progressive increase in atrial thresholds, ranging from 0.49 ± 0.35 (at implantation) to 1.86 ± 1.31 volts (30th postoperative day), in unipolar mode. Atrial impedance measurements decreased slightly over time, ranging from 486.80 ± 126.35 Ohms (at implantation) to 385.0 ± 80.52 Ohms (30th postoperative day). Atrial sensing measures remained stable from the immediate postoperative period until the end of the study. CONCLUSION: The bipolar active fixation endocardial lead implanted epicardially can provide stable conditions of pacing and sensing parameters throughout the postoperative follow-up.

Perfil das intoxicações exógenas em um hospital universitário / Exogenous intoxications profile in a university hospital

Objetivo: este artigo traça um perfil epidemiológico dos pacientes intoxicados porsubstâncias exógenas, de maio a agosto de 2006, no Pronto-Socorro do Hospital das ClínicasSamuel Libânio (HCSL). Pacientes e Métodos: foi aplicado um questionário paracoleta de dados sociodemográficos e clínicos dos pacientes com intoxicação exógena.Os pacientes com menos de 13 anos foram excluídos dessa análise. As variáveis analisadasforam gênero, agente, motivo da intoxicação, tabagismo, uso de drogas ilícitas,etilismo, religião, tempo decorrido entre a intoxicação e o atendimento médico, históriapatogênica pregressa e desfecho do paciente. Como método de análise estatística,as variáveis foram descritas pelas freqüências relativa e absoluta, com discriminaçãoindividualizada. Resultados: foram registradas 46 intoxicações exógenas, a maioriaocorrida no gênero feminino. A média de idade predominante foi de 13 a 20 anos.Os benzodiazepínicos e organofosforados foram as substâncias mais encontradas.Conclusão: o perfil dos pacientes intoxicados encontrados no HCSL coincide com odescrito pela literatura, sendo os benzodiazepínicos e os organofosforados os agentesmais utilizados, alta prevalência no sexo feminino e faixa etária predominante entre 13e 20 anos. Estes achados também enfatizam a nacessidade de se criarem novos centrosde controle de intoxicação, de se criarem pacotes mais seguros para drogas, produtosquímicos e atividades aducativas a fim de modificar esta epidemiologia.