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Arq Bras Cardiol ; 113(3): 449-663, 2019 10 10.
Artigo em Português | MEDLINE | ID: mdl-31621787
Bernoche, Claudia; Timerman, Sergio; Polastri, Thatiane Facholi; Giannetti, Natali Schiavo; Siqueira, Adailson Wagner da Silva; Piscopo, Agnaldo; Soeiro, Alexandre de Matos; Reis, Amélia Gorete Afonso da Costa; Tanaka, Ana Cristina Sayuri; Thomaz, Ana Maria; Quilici, Ana Paula; Catarino, Andrei Hilário; Ribeiro, Anna Christina de Lima; Barreto, Antonio Carlos Pereira; Azevedo, Antonio Fernando Barros de Filho; Pazin, Antonio Filho; Timerman, Ari; Scarpa, Bruna Romanelli; Timerman, Bruno; Tavares, Caio de Assis Moura; Martins, Cantidio Soares Lemos; Serrano, Carlos Vicente Junior; Malaque, Ceila Maria Sant'Ana; Pisani, Cristiano Faria; Batista, Daniel Valente; Leandro, Daniela Luana Fernandes; Szpilman, David; Gonçalves, Diego Manoel; Paiva, Edison Ferreira de; Osawa, Eduardo Atsushi; Lima, Eduardo Gomes; Adam, Eduardo Leal; Peixoto, Elaine; Evaristo, Eli Faria; Azeka, Estela; Silva, Fabio Bruno da; Wen, Fan Hui; Ferreira, Fatima Gil; Lima, Felipe Gallego; Fernandes, Felipe Lourenço; Ganem, Fernando; Galas, Filomena Regina Barbosa Gomes; Tarasoutchi, Flavio; Souza, Germano Emilio Conceição; Feitosa, Gilson Soares Filho; Foronda, Gustavo; Guimarães, Helio Penna; Abud, Isabela Cristina Kirnew; Leite, Ivanhoé Stuart Lima; Linhares, Jaime Paula Pessoa Filho; Moraes, Junior João Batista de Moura Xavier; Falcão, João Luiz Alencar de Araripe; Ramires, Jose Antônio Franchini; Cavalini, José Fernando; Saraiva, José Francisco Kerr; Abrão, Karen Cristine; Pinto, Lecio Figueira; Bianchi, Leonardo Luís Torres; Lopes, Leonardo Nícolau Geisler Daud; Piegas, Leopoldo Soares; Kopel, Liliane; Godoy, Lucas Colombo; Tobase, Lucia; Hajjar, Ludhmila Abrahão; Dallan, Luís Augusto Palma; Caneo, Luiz Fernando; Cardoso, Luiz Francisco; Canesin, Manoel Fernandes; Park, Marcelo; Rabelo, Marcia Maria Noya; Malachias, Marcus Vinícius Bolívar; Gonçalves, Maria Aparecida Batistão; Almeida, Maria Fernanda Branco de; Souza, Maria Francilene Silva; Favarato, Maria Helena Sampaio; Carrion, Maria Julia Machline; Gonzalez, Maria Margarita; Bortolotto, Maria Rita de Figueiredo Lemos; Macatrão-Costa, Milena Frota; Shimoda, Mônica Satsuki; Oliveira-Junior, Mucio Tavares de; Ikari, Nana Miura; Dutra, Oscar Pereira; Berwanger, Otávio; Pinheiro, Patricia Ana Paiva Corrêa; Reis, Patrícia Feitosa Frota dos; Cellia, Pedro Henrique Moraes; Santos Filho, Raul Dias dos; Gianotto-Oliveira, Renan; Kalil Filho, Roberto; Guinsburg, Ruth; Managini, Sandrigo; Lage, Silvia Helena Gelas; Yeu, So Pei; Franchi, Sonia Meiken; Shimoda-Sakano, Tania; Accorsi, Tarso Duenhas; Leal, Tatiana de Carvalho Andreucci; Guimarães, Vanessa; Sallai, Vanessa Santos; Ávila, Walkiria Samuel; Sako, Yara Kimiko.
Arq. bras. cardiol ; 113(3): 449-663, Sept. 2019. tab, graf
Artigo em Português | LILACS, Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1038561
Blood Purif ; 48(4): 336-345, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31336370


BACKGROUND: Renal medullary hypoxia precedes the development of acute kidney injury in experimental sepsis and can now be assessed by continuous measurement of urinary oxygen tension (PuO2). OBJECTIVES: We aimed to test if PuO2 measurements in patients with septic shock would be similar to those shown in experimental sepsis and would detect changes induced by the administration of furosemide. METHOD: Pilot prospective observational cohort study in a tertiary intensive care unit (ICU). Seven adult patients with septic shock admitted to ICU had PuO2 measurements recorded minutely. There were 29 episodes of intravenous furosemide (20 mg n = 19; 40 mg n = 10). RESULTS: The median pre-furosemide PuO2 was low at 21.2 mm Hg (interquartile range [IQR] 17.73-24.86) and increased to 26 mm Hg (IQR 20.27-29.95) at 20 min (p < 0.01), to 27.5 mm Hg (IQR 24.06-33.18) at 40 min (p < 0.01) and to 28.5 mm Hg (IQR 22.65-31.03) at 60 min (p < 0.01). The increase in PuO2 was greater in episodes with a diuretic response >2 mL/kg/h than during episodes without such a response (p < 0.01). CONCLUSIONS: PuO2 measurements in patients are reflective of the low values reported in experimental models of sepsis. PuO2 values increased following furosemide administration with a response independently associated with greater diuresis.

Lesão Renal Aguda/urina , Diuréticos/uso terapêutico , Furosemida/uso terapêutico , Oxigênio/urina , Choque Séptico/urina , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/prevenção & controle , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sepse/complicações , Sepse/urina , Choque Séptico/complicações
J Cardiothorac Vasc Anesth ; 32(6): 2512-2519, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29703580


OBJECTIVES: To investigate the efficacy and safety of perioperative administration of nitric oxide in cardiac surgery. DESIGN: Meta-analysis of randomized controlled trials (RCTs). PARTICIPANTS: Cardiac surgery patients. INTERVENTIONS: A search of Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE for RCTs that compared nitric oxide with placebo or other comparators. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intensive care unit (ICU) stay, and secondary outcomes were mortality, duration of mechanical ventilation, and reduction of mean pulmonary artery pressure. The study included 18 RCTs comprising 958 patients. The authors calculated the pooled odds ratio (OR) and the mean difference (MD) with random-effects model. Quantitative synthesis of data demonstrated a clinically negligible reduction in the length of ICU stay (MD -0.38 days, confidence interval CI [-0.65 to -0.11]; p = 0.005) and mechanical ventilation duration (MD -4.81 hours, CI [-7.79 to -1.83]; p = 0.002) compared with all control interventions with no benefit on mortality. CONCLUSIONS: Perioperative delivery of inhaled nitric oxide resulted to be of no or minimal benefit in patients with pulmonary hypertension undergoing cardiac surgery. Large, randomized trials are needed to further assess its effect on major clinical outcomes and its cost-effectiveness.

Procedimentos Cirúrgicos Cardíacos , Cardiopatias/cirurgia , Hipertensão Pulmonar/tratamento farmacológico , Óxido Nítrico/administração & dosagem , Assistência Perioperatória/métodos , Pressão Propulsora Pulmonar/efeitos dos fármacos , Ensaios Clínicos Controlados Aleatórios como Assunto , Administração por Inalação , Fatores Relaxantes Dependentes do Endotélio/administração & dosagem , Cardiopatias/complicações , Cardiopatias/fisiopatologia , Humanos , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Resultado do Tratamento
Anesthesiology ; 126(1): 85-93, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27841822


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.

Procedimentos Cirúrgicos Cardíacos , Norepinefrina/farmacologia , Complicações Pós-Operatórias/tratamento farmacológico , Choque/tratamento farmacológico , Vasoplegia/tratamento farmacológico , Vasopressinas/farmacologia , Brasil , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque/complicações , Resultado do Tratamento , Vasoconstritores/farmacologia , Vasoplegia/complicações
J Thorac Cardiovasc Surg ; 150(5): 1314-20, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26318355


OBJECTIVE: The aim of this study was to compare outcomes in patients undergoing cardiac surgery who are aged 60 years or more or less than 60 years after implementation of a restrictive or a liberal transfusion strategy. METHODS: This is a substudy of the Transfusion Requirements After Cardiac Surgery (TRACS) randomized controlled trial. In this subgroup analysis, we separated patients into those aged 60 years or more (elderly) and those aged less than 60 years randomized to a restrictive or a liberal strategy of red blood cell transfusion. The primary outcome was a composite defined as a combination of 30-day all-cause mortality and severe morbidity. RESULTS: Of the 502 patients included in the Transfusion Requirements After Cardiac Surgery study, 260 (51.8%) were aged 60 years or more and 242 (48.2%) were aged less than 60 years and were included in this study. The primary end point occurred in 11.9% of patients in the liberal strategy group and 16.8% of patients in the restrictive strategy group (P = .254) for those aged 60 years or more and in 6.8% of patients in the liberal strategy group and 5.6% of patients in the restrictive strategy group for those aged less than 60 years (P = .714). However, in the older patients, cardiogenic shock was more frequent in patients in the restrictive transfusion group (12.8% vs 5.2%, P = .031). Thirty-day mortality, acute respiratory distress syndrome, and acute renal injury were similar in the restrictive and liberal transfusion groups in both age groups. CONCLUSIONS: Although there was no difference between groups regarding the primary outcome, a restrictive transfusion strategy may result in an increased rate of cardiogenic shock in elderly patients undergoing cardiac surgery compared with a more liberal strategy. Cardiovascular risk of anemia may be more harmful than the risk of blood transfusion in older patients.

Anemia/terapia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Transfusão de Eritrócitos/métodos , Choque Cardiogênico/prevenção & controle , Adulto , Fatores Etários , Idoso , Anemia/sangue , Anemia/diagnóstico , Anemia/mortalidade , Biomarcadores/sangue , Brasil , Procedimentos Cirúrgicos Cardíacos/mortalidade , Transfusão de Eritrócitos/efeitos adversos , Transfusão de Eritrócitos/mortalidade , Hematócrito , Hemoglobinas/metabolismo , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Fatores de Tempo , Resultado do Tratamento
Curr Opin Anaesthesiol ; 28(1): 81-8, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25486489


PURPOSE OF REVIEW: Anemia has been demonstrated to be detrimental in several populations such as high-surgical-risk patients, critically ill elderly, and cardiac patients. Red blood cell transfusion is the most commonly prescribed therapy for anemia. Despite being life-saving, it carries a risk that ranges from mild complications to death. The aim of this review is to discuss the risks of anemia and blood transfusion, and to describe recent developments in the strategies to reduce allogeneic blood transfusion. RECENT FINDINGS: In the past decades, clinical studies comparing transfusion strategies in different populations were conducted. Despite the challenges imposed by the development of such studies, evidence-based medicine on transfusion medicine in critically ill patients is being created. Different results arising from these studies reflect population heterogeneity, specific circumstances, and difficulties in measuring the impact of anemia and transfusion in a clinical trial. SUMMARY: An adequate judgment of a clinical condition associated with proper application of the available literature is the cornerstone in the management of transfusion in critical care. Apart from this individualized strategy, the institution of a patient blood management program allows goal-directed approach through preoperative recognition of anemia, surgical efforts to minimize blood loss, and continuous assessment of the coagulation status.

Transfusão de Sangue/métodos , Transfusão de Sangue/estatística & dados numéricos , Anemia/etiologia , Transfusão de Eritrócitos , Humanos , América Latina , Ensaios Clínicos Controlados Aleatórios como Assunto , Reação Transfusional
São Paulo; s.n; 2015. [105] p. ilus, tab, graf.
Tese em Português | LILACS | ID: biblio-871535


Introdução: O objetivo do estudo foi avaliar os efeitos da terapia guiada por metas (TGM) sobre desfechos em pacientes de alto risco submetidos à cirurgia cardíaca. Métodos: Estudo prospectivo randomizado que avaliou 126 pacientes submetidos às cirurgias de revascularização do miocárdio ou valvar internados na Unidade de Terapia Intensiva Cirúrgica (UTI) do Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo. Os pacientes foram randomizados para um algoritmo de terapia guiada por metas (grupo TGM, n=62) ou grupo controle (n=64). No grupo TGM, um índice cardíaco superior a 3 L/min/m2 foi utilizado como alvo através de fluidos, inotrópicos e transfusão de concentrado de hemácias, com início após desmame da circulação extracorpórea e com término após 8 horas de admissão na UTI. Resultados: O desfecho primário foi um composto de mortalidade e complicações maiores em 30 dias. Os pacientes do grupo TGM receberam maior volume (mediana e intervalo interquartílico) de fluidos em relação ao grupo controle [1000 (625 - 1500) vs. 500 (500 - 1000) mL (P < 0,001)], e não houve diferença na administração de inotrópicos ou hemotransfusão. A incidência do desfecho primário foi menor no grupo TGM (27,4 vs. 45,3%, p=0,037). O grupo TGM apresentou menor incidência de infecção (12,9 vs. 29,7%, P=0,002) síndrome do baixo débito cardíaco (6,5 vs. 26,6%, P=0.002). Foram também observados menor dose acumulada de dobutamina (12 vs. 19 mg/Kg, P=0,003), menor tempo de internação na UTI (3 [3-4] vs. 5 [4-7] dias; P < 0,001) e no hospital (9 [8-16] vs. 12 [9-22] dias, P=0,049) no grupo TGM comparado ao grupo controle. Não houve diferença nas taxas de mortalidade em 30 dias. (4,8% vs. 9,4%, respectivamente; P = 0,492). Conclusão: A estratégia de terapia guiada por metas através de fluidos, inotrópicos e transfusão sanguínea reduziu a incidência de complicações maiores em 30 dias em pacientes de alto risco submetidos a cirurgia cardíaca.

Introduction: The objective of the study was to evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. Methods: A prospective randomized controlled trial that evaluated 126 patients undergoing coronary artery bypass or valve repair in a Surgical Intensive Care Unit (ICU) of the Heart Institute/Faculty of Medicine of University of Sao Paulo. Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (GDT group, n=62) or to usual care (n=64). In the GDT arm, a cardiac index of greater than 3 L/min/m2 was targeted with intravenous fluids, inotropes and red blood cell transfusion starting from cardiopulmonary bypass and ending eight hours after arrival to the ICU. Results: The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the GDT group received a greater median (interquartile range) volume of intra-venous fluids than the usual care group [1000 (625 - 1500) vs. 500 (500 - 1000) mL (P<0.001)], with no differences in the administration of either inotropes or red blood cell transfusions. The primary outcome was reduced in the GDT group (27.4 vs. 45.3%, p=0.037). The GDT group had a lower incidence of infection (12.9 vs. 29.7%, P=0.002) and low cardiac output syndrome (6.5 vs. 26.6%, P=0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs. 19 mg/Kg, P=0.003) and a shorter ICU (3 [3-4] vs. 5 [4-7] days; P < 0.001) and hospital length of stay (9 [8-16] vs. 12 [9-22] days, P=0.049) in the GDT compared to the usual care group. There were no differences in 30-day mortality rates (4.8% vs. 9.4%, respectively; P = 0.492). Conclusions: Goal directed therapy using fluids, inotropes and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.

Humanos , Adulto , Hemodinâmica , Complicações Pós-Operatórias , Estudos Prospectivos , Ressuscitação , Cirurgia Torácica