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1.
J Nephrol ; 2019 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-31515724

RESUMO

Hypophosphatemia is a common but often underestimated electrolyte derangement among intensive care unit (ICU) patients. Low phosphate levels can lead to cellular dysfunction with potentially relevant clinical manifestations (e.g., muscle weakness, respiratory failure, lethargy, confusion, arrhythmias). In critically ill patients with severe acute kidney injury (AKI) renal replacement therapies (RRTs) represent a well-known risk factor for hypophosphatemia, especially if the most intensive and prolonged modalities of RRT, such as continuous RRT or prolonged intermittent RRT, are used. Currently, no evidence-based specific guidelines are available for the treatment of hypophosphatemia in the critically ill; however, considering the potentially negative impact of hypophosphatemia on morbidity and mortality, strategies aimed at reducing its incidence and severity should be timely implemented in the ICUs. In the clinical setting of critically ill patients on RRT, the most appropriate strategy could be to anticipate the onset of RRT-related hypophosphatemia by implementing the use of phosphate-containing solutions for RRT through specifically designed protocols. The present review is aimed at summarizing the most relevant evidence concerning epidemiology, prognostic impact, prevention and treatment of hypophosphatemia in critically ill patients with AKI on RRT, with a specific focus on RRT-induced hypophosphatemia.

2.
J Immunol Res ; 2019: 9782594, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31467936

RESUMO

Monocytes are a heterogeneous cell population distinguished into three subsets with distinctive phenotypic and functional properties: "classical" (CD14++CD16-), "intermediate" (CD14++CD16+), and "nonclassical" (CD14+CD16++). Monocyte subsets play a pivotal role in many inflammatory systemic diseases including atherosclerosis (ATS). Only a low number of studies evaluated monocyte behavior in patients affected by cardiovascular diseases, and data about their role in acute aortic dissection (AAD) are lacking. Thus, the aim of this study was to investigate CD14++CD16-, CD14++CD16+, and CD14+CD16++ cells in patients with Stanford-A AAD and in patients with carotid artery stenosis (CAS). Methods. 20 patients with carotid artery stenosis (CAS group), 17 patients with Stanford-A AAD (AAD group), and 17 subjects with traditional cardiovascular risk factors (RF group) were enrolled. Monocyte subset frequency was determined by flow cytometry. Results. Classical monocytes were significantly increased in the AAD group versus CAS and RF groups, whereas intermediate monocytes were significantly decreased in the AAD group versus CAS and RF groups. Conclusions. Results of this study identify in AAD patients a peculiar monocyte array that can partly explain depletion of T CD4+ lymphocyte subpopulations observed in patients affected by AAD.

3.
Minerva Anestesiol ; 2019 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-31213042

RESUMO

Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve Cardiac Output and Oxygen Delivery (Goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29,1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.

4.
Echocardiography ; 36(5): 992-995, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30873637

RESUMO

A 20-year-old Congolese woman presented with presyncope, dyspnea, and anasarca. Past medical history was unremarkable. Echocardiography revealed a rare combination of giant right atrium (RA), a dilated and hypertrophied right ventricle, subvalvular pulmonary stenosis (subPS), severe tricuspid regurgitation (TR), pericardial effusion and what appeared to be a spontaneously closed ventricular septal defect (VSD). Cardiac Magnetic Resonance and Cardiac Computed Tomography confirmed the findings excluding the presence of intra-cardiac and extra-cardiac shunt and other associated congenital anomalies. The patient underwent subPS resection, right atrioplasty, and tricuspid annuloplasty. Multimodality approach facilitated the detection of the abnormalities and provided clarity when determining the optimal surgical strategy.

5.
Turk J Anaesthesiol Reanim ; 46(3): 176-183, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30140512

RESUMO

Objective: Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice. Methods: A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data. Results: Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects. Conclusion: DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.

7.
J Cardiothorac Vasc Anesth ; 32(6): 2459-2466, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29929893

RESUMO

OBJECTIVE: There is increasing burnout incidence among medical disciplines, and physicians working in emergency settings seem at higher risk. Cardiac anesthesiology is a stressful anesthesiology subspecialty dealing with high-risk patients. The authors hypothesized a high risk of burnout in cardiac anesthesiologists. DESIGN: National survey conducted on burnout. SETTING: Italian cardiac centers. PARTICIPANTS: Cardiac anesthesiologists. INTERVENTIONS: The authors administered via email an anonymous questionnaire divided into 3 parts. The first 2 parts evaluated workload and private life. The third part consisted of the Maslach Burnout Inventory test with its 3 constituents: high emotional exhaustion, high depersonalization, and low personal accomplishment. MEASUREMENTS AND MAIN RESULTS: The authors measured the prevalence and risk of burnout through the Maslach Burnout Inventory questionnaire and analyzed factors influencing burnout. Among 670 contacts from 71 centers, 382 cardiac anesthesiologists completed the survey (57%). The authors found the following mean Maslach Burnout Inventory values: 14.5 ± 9.7 (emotional exhaustion), 9.1 ± 7.1 (depersonalization), and 33.7 ± 8.9 (personal accomplishment). A rate of 34%, 54%, and 66% of respondents scored in "high" or "moderate-high" risk of burnout (emotional exhaustion, depersonalization, and personal accomplishment, respectively). The authors found that, if offered to change subspecialty, 76% of respondents would prefer to remain in cardiac anesthesiology. This preference and parenthood were the only 2 investigated factors with a protective effect against all components of burnout. Significantly lower burnout scores were found in more experienced anesthesiologists. CONCLUSION: A relatively high incidence of burnout was found in cardiac anesthesiologists, especially regarding high depersonalization and low personal accomplishment. Nonetheless, most of the respondents would choose to remain in cardiac anesthesiology.

9.
Crit Care ; 21(1): 252, 2017 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-29047417

RESUMO

BACKGROUND: Previous studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan. METHODS: We performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion. RESULTS: Six RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p = 0.02), and a trend toward lower mechanical support, both overall (p = 0.07) and in patients with LVEF < 35% (p = 0.05). CONCLUSIONS: Levosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.


Assuntos
Baixo Débito Cardíaco/tratamento farmacológico , Procedimentos Cirúrgicos Cardíacos/métodos , Hidrazonas/farmacologia , Piridazinas/farmacologia , Função Ventricular Esquerda/efeitos dos fármacos , Cardiotônicos/farmacologia , Cardiotônicos/uso terapêutico , Humanos , Hidrazonas/uso terapêutico , Piridazinas/uso terapêutico , Simendana , Volume Sistólico/efeitos dos fármacos
10.
Anesthesiology ; 127(6): 918-933, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28872484

RESUMO

BACKGROUND: Ischemic myocardial damage accompanying coronary artery bypass graft surgery remains a clinical challenge. We investigated whether xenon anesthesia could limit myocardial damage in coronary artery bypass graft surgery patients, as has been reported for animal ischemia models. METHODS: In 17 university hospitals in France, Germany, Italy, and The Netherlands, low-risk elective, on-pump coronary artery bypass graft surgery patients were randomized to receive xenon, sevoflurane, or propofol-based total intravenous anesthesia for anesthesia maintenance. The primary outcome was the cardiac troponin I concentration in the blood 24 h postsurgery. The noninferiority margin for the mean difference in cardiac troponin I release between the xenon and sevoflurane groups was less than 0.15 ng/ml. Secondary outcomes were the safety and feasibility of xenon anesthesia. RESULTS: The first patient included at each center received xenon anesthesia for practical reasons. For all other patients, anesthesia maintenance was randomized (intention-to-treat: n = 492; per-protocol/without major protocol deviation: n = 446). Median 24-h postoperative cardiac troponin I concentrations (ng/ml [interquartile range]) were 1.14 [0.76 to 2.10] with xenon, 1.30 [0.78 to 2.67] with sevoflurane, and 1.48 [0.94 to 2.78] with total intravenous anesthesia [per-protocol]). The mean difference in cardiac troponin I release between xenon and sevoflurane was -0.09 ng/ml (95% CI, -0.30 to 0.11; per-protocol: P = 0.02). Postoperative cardiac troponin I release was significantly less with xenon than with total intravenous anesthesia (intention-to-treat: P = 0.05; per-protocol: P = 0.02). Perioperative variables and postoperative outcomes were comparable across all groups, with no safety concerns. CONCLUSIONS: In postoperative cardiac troponin I release, xenon was noninferior to sevoflurane in low-risk, on-pump coronary artery bypass graft surgery patients. Only with xenon was cardiac troponin I release less than with total intravenous anesthesia. Xenon anesthesia appeared safe and feasible.


Assuntos
Anestesia Intravenosa , Ponte de Artéria Coronária/tendências , Internacionalidade , Éteres Metílicos/administração & dosagem , Troponina I/sangue , Xenônio/administração & dosagem , Idoso , Anestésicos Inalatórios/administração & dosagem , Biomarcadores/sangue , Ponte de Artéria Coronária/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Sevoflurano , Método Simples-Cego , Resultado do Tratamento
11.
Mycoses ; 60(12): 826-829, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28877374

RESUMO

Duration >120 minutes of extracorporeal circulation (ECC) during cardiopulmonary bypass procedure was associated to an increased risk of candidemia in the intensive care unit (ICU). To evaluate oral nystatin prophylaxis in cardiac surgery considering its exclusive effect on Candida, in the absence of systemic effects and selection of resistant strains to polyene. We conducted an observational study in the postcardiac surgery ICU of Policlinico "Umberto I" of Rome. From January 2014, all patients with a prolonged ECC >120 minutes were systematically treated with oral nystatin (Prophylaxis group). This group was compared with all patients hospitalised in the same ICU, who have not received oral nystatin after ECC >120 minutes (No prophylaxis group). Overall, 672 consecutive patients were analyzed: 318 (47.3%) patients belonged to the no prophylaxis group, and 354 (52.7%) patients to the prophylaxis group. Diagnosis of candidemia was confirmed in 7 (2.2%) patients, all belonged to the no prophylaxis group. At multivariate analysis, oral nystatin prophylaxis showed a protective effect for development of candidemia after cardiac surgery. Oral nystatin prophylaxis, in patients who underwent a ECC >120 minutes, seems to reduce development of candidemia; however, the real efficacy of such prophylaxis approach requires further investigation.


Assuntos
Antifúngicos/administração & dosagem , Candidíase/prevenção & controle , Ponte Cardiopulmonar/efeitos adversos , Circulação Extracorpórea/efeitos adversos , Nistatina/administração & dosagem , Idoso , Candida/classificação , Candida/efeitos dos fármacos , Candida/genética , Candida/isolamento & purificação , Candidíase/tratamento farmacológico , Candidíase/etiologia , Candidíase/microbiologia , Feminino , Cardiopatias/cirurgia , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade
12.
13.
Blood Purif ; 44(1): 8-15, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28219057

RESUMO

AIMS: To evaluate the efficacy and safety of a commercially available phosphate-containing solution for continuous renal replacement therapy (CRRT) in preventing CRRT-related hypophosphatemia. METHODS: In heart surgery patients undergoing continuous veno-venous haemodiafiltration (CVVHDF) with regional citrate anticoagulation (RCA), we combined an 18 mmol/l citrate solution with a phosphate-containing (1.2 mmol/l) dialysate/replacement fluid evaluating the incidence of hypophosphatemia and the need for parenteral phosphorus supplementation. RESULTS: In 75 patients on RCA-CVVHDF, the mean filter life was 53.9 ± 33.6 h. Regardless of baseline levels, phosphoremia was progressively corrected and maintained in a narrow normality range throughout RCA-CRRT days (after 72 h: 1.14 ± 0.25 mmol/l). Considering the whole CRRT period, 45 out of 975 (4.6%) serum phosphorus determinations met the criteria for mild (<0.81 mmol/l) or moderate (<0.61 mmol/l) hypophosphatemia; severe hypophosphatemia (<0.32 mmol/l) never occurred. After 72 h 88% of the patients were normophosphatemic, 9% hyperphosphatemic and 3% hypophosphatemic. CONCLUSIONS: RCA-CVVHDF with a phosphate-containing solution enabled the maintenance of phosphorus levels within normophosphatemic range in most of the patients, minimizing the occurrence of CRRT-related hypophosphatemia.


Assuntos
Soluções para Diálise/química , Hipofosfatemia/prevenção & controle , Terapia de Substituição Renal/efeitos adversos , Idoso , Coagulação Sanguínea/efeitos dos fármacos , Procedimentos Cirúrgicos Cardíacos/métodos , Citratos , Feminino , Humanos , Hipofosfatemia/etiologia , Masculino , Pessoa de Meia-Idade , Fosfatos , Estudos Retrospectivos , Resultado do Tratamento
14.
Ann Med ; 49(4): 283-290, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27690642

RESUMO

BACKGROUND: Atherosclerosis is a multifactorial disease characterized by an immune-inflammatory remodeling of the arterial wall. Treg and Th17 subpopulations are detectable inside atherosclerotic plaque; however, their behavior in symptomatic carotid artery stenosis (CAS) is not fully elucidated. The aim of this study was to evaluate Th17 and Treg subsets and their ratio in patients affected by symptomatic and asymptomatic CAS. METHODS: 14 patients with symptomatic CAS (CAS-S group), 41 patients with asymptomatic CAS (CAS-A group), 32 subjects with traditional cardiovascular risk factors (RF group), and 10 healthy subjects (HS group) were enrolled. Th17 and Treg frequency was determined by flow cytometry and by histology and immunohistochemistry. Interleukin (IL)-10, IL-17, and metalloproteinase (MMP)-12 levels were measured by ELISA. RESULTS: Th17 were significantly increased in CAS-A versus RF and versus HS. Tregs were significantly increased in CAS-S versus CAS-A. Tregs/Th17 ratio was significantly reduced in CAS-A versus RF and versus HS, whereas it was significantly increased in CAS-S versus CAS-A. CONCLUSIONS: The results of this study suggest that Th17 are related to the late stages of CAS but not to plaque instability. Moreover, Treg expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with brain injury. KEY MESSAGES Tregs expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with CD4+ effector depletion and brain ischemic injury. Th17 lymphocytes are related to the late stages of CAS but not to plaque instability.


Assuntos
Linfócitos T CD4-Positivos/metabolismo , Estenose das Carótidas/imunologia , Subunidade alfa de Receptor de Interleucina-2/metabolismo , Linfócitos T Reguladores/metabolismo , Células Th17/metabolismo , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/metabolismo , Feminino , Humanos , Interleucina-10/metabolismo , Interleucina-17/metabolismo , Masculino , Metaloproteinase 12 da Matriz/metabolismo , Pessoa de Meia-Idade
15.
Minerva Anestesiol ; 82(10): 1023-1025, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27327856
16.
J Clin Monit Comput ; 30(3): 347-65, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26089166

RESUMO

This study was to investigate and define what is considered as a current clinical practice in hemodynamic monitoring and vasoactive medication use after cardiac surgery in Italy. A 33-item questionnaire was sent to all intensive care units (ICUs) admitting patients after cardiac surgery. 71 out of 92 identified centers (77.2 %) returned a completed questionnaire. Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature and blood gas analysis were identified as routinely used hemodynamic monitoring, whereas advanced monitoring was performed with pulmonary artery catheter or echocardiography. Crystalloids were the fluids of choice for volume replacement (86.8 % of Centers). To guide volume management, central venous pressure (26.7 %) and invasive blood pressure (19.7 %) were the most frequently used parameters. Dobutamine was the first choice for treatment of left heart dysfunction (40 %) and epinephrine was the first choice for right heart dysfunction (26.8 %). Half of the Centers had an internal protocol for vasoactive drugs administration. Intra-aortic balloon pump and extra-corporeal membrane oxygenation were widely available among Cardiothoracic ICUs. Angiotensin-converting enzyme inhibitors were suspended in 28 % of the Centers. The survey shows what is considered as standard monitoring in Italian Cardiac ICUs. Standard, routinely used monitoring consists of ECG, SpO2, etCO2, invasive BP, CVP, diuresis, body temperature, and BGA. It also shows that there is large variability among the various Centers regarding hemodynamic monitoring of fluid therapy and inotropes administration. Further research is required to better standardize and define the indicators to improve the standards of intensive care after cardiac surgery among Italian cardiac ICUs.


Assuntos
Procedimentos Cirúrgicos Cardíacos/normas , Monitorização Intraoperatória/normas , Adulto , Circulação Assistida , Transfusão de Sangue , Cardiotônicos/uso terapêutico , Hidratação/normas , Hemodinâmica , Humanos , Unidades de Terapia Intensiva , Itália , Padrão de Cuidado , Inquéritos e Questionários , Vasoconstritores/uso terapêutico
17.
J Nephrol ; 29(2): 229-239, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26022723

RESUMO

BACKGROUND: Acute kidney injury (AKI) represents a major complication of cardiac surgery. Our aim was to evaluate, in patients undergoing continuous renal replacement therapy (CRRT) for cardiac surgery-associated AKI (CS-AKI), prognostic factors related to in-hospital survival and renal function recovery to independence from RRT. METHODS: We conducted a retrospective analysis in patients with severe CS-AKI who underwent CRRT for at least 48 h. The sequential organ failure assessment (SOFA) score was calculated on a daily basis to evaluate illness severity throughout the intensive care unit (ICU) stay. RESULTS: In 264 patients (age 66.4 ± 11.7 years, 192 males), 30-day survival was 57.6 % while survival to discharge from the hospital was 40.5 %. Renal function recovery occurred in 96.3 % of survivors and in 13.4 % of non-survivors (p < 0.001). Multivariate analysis selected advancing age, oliguria, sepsis and the highest level of SOFA score within the first week of CRRT (SOFA-max) as independent prognostic factors for failure to recover renal function. Female gender was associated with a higher probability of survival, while higher serum creatinine at the start of CRRT, oliguria, sepsis and SOFA-max were independently associated with mortality. The subgroup of patients with a day-1 SOFA score above the median (≥10) showed a lower probability of survival and a lower cumulative incidence of renal function recovery. CONCLUSIONS: In a selected population of patients with severe CS-AKI requiring RRT, short-term outcomes appear strongly associated with the worst grade of illness severity during the first week of CRRT, thus reflecting the sequential occurrence of additional major complications during ICU stay. Renal function recovery and in-hospital survival appear mutually linked, sharing oliguria, sepsis and SOFA score as the main determinants of both outcomes.


Assuntos
Lesão Renal Aguda/terapia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Terapia de Substituição Renal , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Distribuição de Qui-Quadrado , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Oligúria/etiologia , Escores de Disfunção Orgânica , Alta do Paciente , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Recuperação de Função Fisiológica , Terapia de Substituição Renal/efeitos adversos , Terapia de Substituição Renal/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sepse/etiologia , Índice de Gravidade de Doença , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
18.
Forensic Sci Int ; 256: 17-20, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26332046

RESUMO

Paravertebral block (PVB) is the technique of injecting a local anesthetic solution alongside the vertebral column, close to where the spinal nerves emerge, resulting in unilateral somatic and sympathetic nerve blockade. Here is reported a fatal case involving a 60-year-old woman with spondylitis arthropathy, who developed cardiac and respiratory arrest 40min after receiving an accidental subarachnoid injection (L5-S1 bilaterally) of depomedrol lidocaine and levobupivacaine. A complete autopsy including histological and toxicological analyses was performed in order to establish the cause of death. Liquid/liquid extraction (LLE) and GC-MS analysis were performed according to a previously published method. Lidocaine and bupivacaine were detected both in blood, at concentrations of 14.8mg/L and 13.3mg/L respectively, and in cerebrospinal fluid (CSF) at concentrations of 287.1mg/L and 464.2mg/L respectively. Both lidocaine and bupivacaine were also detected in the urine. The toxicological findings along with the autopsy allowed us to establish that the accidental subarachnoid injection of lidocaine and levobupivacaine had led to a progressive hypotension and normovolaemic shock caused by a severe ganglionic block, determining the patient's death.


Assuntos
Anestésicos Locais/efeitos adversos , Bupivacaína/análogos & derivados , Injeções/efeitos adversos , Lidocaína/efeitos adversos , Erros de Medicação , Bloqueio Nervoso/métodos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/análise , Bupivacaína/administração & dosagem , Bupivacaína/efeitos adversos , Bupivacaína/análise , Evolução Fatal , Feminino , Parada Cardíaca/induzido quimicamente , Humanos , Levobupivacaína , Lidocaína/administração & dosagem , Lidocaína/análise , Pessoa de Meia-Idade , Insuficiência Respiratória/induzido quimicamente , Espaço Subaracnóideo
19.
Ann Med ; 47(6): 441-6, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26339779

RESUMO

Acute aortic dissection (AAD) is a life-threatening disease with an incidence of about 2.6-3.6 cases per 100,000/year. Depending on the site of rupture, AAD is classified as Stanford-A when the ascending aortic thoracic tract and/or the arch are involved, and Stanford-B when the descending thoracic aorta and/or aortic abdominal tract are targeted. It was recently shown that inflammatory pathways underlie aortic rupture in both type A and type B Stanford AAD. An immune infiltrate has been found within the middle and outer tunics of dissected aortic specimens. It has also been observed that the recall and activation of macrophages inside the middle tunic are key events in the early phases of AAD. Macrophages are able to release metalloproteinases (MMPs) and pro-inflammatory cytokines which, in turn, give rise to matrix degradation and neoangiogenesis. An imbalance between the production of MMPs and MMP tissue inhibitors is pivotal in the extracellular matrix degradation underlying aortic wall remodelling in dissections occurring both in inherited conditions and in atherosclerosis. Among MMPs, MMP-12 is considered a specific marker of aortic wall disease, whatever the genetic predisposition may be. The aim of this review is, therefore, to take a close look at the immune-inflammatory mechanisms underlying Stanford-A AAD.


Assuntos
Aneurisma Dissecante/enzimologia , Aneurisma Dissecante/patologia , Aneurisma da Aorta Torácica/metabolismo , Inflamação/enzimologia , Inflamação/patologia , Metaloproteases/metabolismo , Animais , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/epidemiologia , Humanos
20.
Steroids ; 99(Pt B): 189-93, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25668615

RESUMO

The human brain contains approximately 25% of the body's cholesterol. The brain is separated from the circulation by the blood brain barrier. While cholesterol will not passes this barrier, oxygenated forms of cholesterol can cross the barrier. Here by measuring the difference in the oxysterol content of blood plasma in the jugular vein and in a forearm vein by mass spectrometry (MS) we were able to determine the flux of more than 20 cholesterol metabolites between brain and the circulation. We confirm that 24S-hydroxycholesterol is exported from brain at a rate of about 2-3mg/24h. Gas chromatography (GC)-MS data shows that the cholesterol metabolites 5α-hydroxy-6-oxocholesterol (3ß,5α-dihydroxycholestan-6-one), 7ß-hydroxycholesterol and 7-oxocholesterol, generally considered to be formed through reactive oxygen species, are similarly exported from brain at rates of about 0.1, 2 and 2mg/24h, respectively. Although not to statistical significance both GC-MS and liquid chromatography (LC)-MS methods indicate that (25R)26-hydroxycholesterol is imported to brain, while LC-MS indicates that 7α-hydroxy-3-oxocholest-4-enoic acid is exported from brain.


Assuntos
Encéfalo/metabolismo , Colesterol/metabolismo , Metaboloma , Cromatografia Líquida , Feminino , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Masculino
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