Finger photopletysmography detects early acute blood loss in compensated blood donors: a pilot study.

Objective.Diagnosis of incipient acute hypovolemia is challenging as vital signs are typically normal and patients remain asymptomatic at early stages. The early identification of this entity would affect patients' outcome if physicians were able to treat it precociously. Thus, the development of a noninvasive, continuous bedside monitoring tool to detect occult hypovolemia before patients become hemodynamically unstable is clinically relevant. We hypothesize that pulse oximeter's alternant (AC) and continuous (DC) components of the infrared light are sensitive to acute and small changes in patient's volemia. We aimed to test this hypothesis in a cohort of healthy blood donors as a model of slight hypovolemia.Approach.We planned to prospectively study blood donor volunteers removing 450 ml of blood in supine position. Noninvasive arterial blood pressure, heart rate, and finger pulse oximetry were recorded. Data was analyzed before donation, after donation and during blood auto-transfusion generated by the passive leg-rising (PLR) maneuver.Main results.Sixty-six volunteers (44% women) accomplished the protocol successfully. No clinical symptoms of hypovolemia, arterial hypotension (systolic pressure < 90 mmHg), brady-tachycardia (heart rate <60 and >100 beats-per-minute) or hypoxemia (SpO2< 90%) were observed during donation. The AC signal before donation (median 0.21 and interquartile range 0.17 a.u.) increased after donation [0.26(0.19) a.u;p< 0.001]. The DC signal before donation [94.05(3.63) a.u] increased after blood extraction [94.65(3.49) a.u;p< 0.001]. When the legs' blood was auto-transfused during the PLR, the AC [0.21(0.13) a.u.;p= 0.54] and the DC [94.25(3.94) a.u.;p= 0.19] returned to pre-donation levels.Significance.The AC and DC components of finger pulse oximetry changed during blood donation in asymptomatic volunteers. The continuous monitoring of these signals could be helpful in detecting occult acute hypovolemia. New pulse oximeters should be developed combining the AC/DC signals with a functional hemodynamic monitoring of fluid responsiveness to define which patient needs fluid administration.

The alteration of neuronal activities of the cuneiform nucleus in non-hypovolemic and hypovolemic hypotensive conditions.

BACKGROUND: The cuneiform nucleus is located in the center of the circuit that mediates autonomic responses to stress. Hemorrhagic hypotension leads to chemoreceptor anoxia, which consequently results in the reduction of baroreceptor discharge and stimulation of the chemoreceptor. OBJECTIVE: Using the single-unit recording technique, the neuronal activities of the cuneiform nucleus were investigated in hypotensive states induced by hemorrhage and administration of an anti-hypertensive drug (hydralazine). METHODS: Thirty male rats were divided into the control, hemorrhage, and hydralazine groups. The femoral artery was cannulated for the recording of cardiovascular responses, including systolic blood pressure, mean arterial pressure, and heart rate. Hydralazine was administered via tail vein. The single-unit recording was performed from the cuneiform nucleus. RESULTS: The maximal systolic blood pressure and the mean arterial pressure significantly decreased and heart rate significantly increased after the application of hydralazine as well as the following hemorrhage compared to the control group. Hypotension significantly increased the firing rate of the cuneiform nucleus in both the hemorrhage and hydralazine groups compared to the control group. CONCLUSIONS: The present data indicate that the cuneiform nucleus activities following hypotension may play a crucial role in blood vessels and vasomotor tone.

The alteration of neuronal activities of the cuneiform nucleus in non-hypovolemic and hypovolemic hypotensive conditions / Alterações da atividade neuronal no núcleo cuneiforme em condições hipovolêmicas e não hipovolêmicas

Abstract Background: The cuneiform nucleus is located in the center of the circuit that mediates autonomic responses to stress. Hemorrhagic hypotension leads to chemoreceptor anoxia, which consequently results in the reduction of baroreceptor discharge and stimulation of the chemoreceptor. Objective: Using the single-unit recording technique, the neuronal activities of the cuneiform nucleus were investigated in hypotensive states induced by hemorrhage and administration of an anti-hypertensive drug (hydralazine). Methods: Thirty male rats were divided into the control, hemorrhage, and hydralazine groups. The femoral artery was cannulated for the recording of cardiovascular responses, including systolic blood pressure, mean arterial pressure, and heart rate. Hydralazine was administered via tail vein. The single-unit recording was performed from the cuneiform nucleus. Results: The maximal systolic blood pressure and the mean arterial pressure significantly decreased and heart rate significantly increased after the application of hydralazine as well as the following hemorrhage compared to the control group. Hypotension significantly increased the firing rate of the cuneiform nucleus in both the hemorrhage and hydralazine groups compared to the control group. Conclusions: The present data indicate that the cuneiform nucleus activities following hypotension may play a crucial role in blood vessels and vasomotor tone.

RESUMO Antecedentes: O núcleo cuneiforme está localizado no centro do circuito que media as respostas autonômicas ao estresse. A hipotensão hemorrágica leva à anóxia dos quimiorreceptores, que, consequentemente, resulta na redução da descarga dos barorreceptores e estimulação do quimiorreceptor. Objetivo: Utilizando a técnica de registro em unidade única, as atividades neuronais do núcleo cuneiforme foram investigadas em estados de hipotensão induzida por hemorragia e administração de um anti-hipertensivo (hidralazina). Métodos: Trinta ratos machos foram divididos nos grupos controle, hemorragia e hidralazina. A artéria femoral foi canulada, para o registro de respostas cardiovasculares, incluindo pressão arterial sistólica, pressão arterial média e frequência cardíaca. A hidralazina foi administrada na veia da cauda. O registro de unidade única foi realizado a partir do núcleo cuneiforme. Resultados: A pressão arterial sistólica máxima e a pressão arterial média diminuíram significativamente, e a frequência cardíaca aumentou significativamente após a aplicação de hidralazina, bem como a hemorragia seguinte, em comparação com o grupo controle. A hipotensão aumentou significativamente a taxa de disparo da população do núcleo cuneiforme em ambos os grupos de hemorragia e hidralazina, em comparação com o grupo de controle. Conclusões: Os presentes dados indicam que as atividades do núcleo cuneiforme após hipotensão podem desempenhar um papel crucial nos vasos sanguíneos e no tônus vasomotor.

Hemoperitoneo secundario a rotura de carcinoma hepatocelular / Hemoperitoneum secondary to rupture of hepatocellular carcinoma

Introducción: El carcinoma hepatocelular es un tumor hipervascular compuesto por vasos sanguíneos anormales, constituye la forma más frecuente de cáncer primario del hígado. Alrededor del 90 por ciento de estos tumores se desarrollan sobre una enfermedad hepática previa. Un aumento en la carga vascular debido a la hipertensión portal conlleva a sangrado. Objetivo: Presentar un paciente a quien se le practicó laparotomía exploradora de urgencia por hemoperitoneo de gran cuantía secundario a una rotura intratumoral sobre un hígado cirrótico. Caso clínico: Paciente de 66 años de edad, con antecedentes patológicos de diabetes mellitus tipo 2, hiperplasia benigna de próstata, alcoholismo crónico y cirrosis hepática. Acudió al cuerpo de guardia por dolor abdominal difuso y signos de hipovolemia aguda. Se realizó laparotomía de urgencia y se constata hemoperitoneo de gran cuantía, secundario a una rotura intratumoral. Se le realizó aspiración de contenido hemático, electrocoagulación y compresión por empaquetamiento. Se controló el sangrado. El paciente tuvo una evolución tórpida y falleció 24 horas posteriores a la laparotomía. Conclusiones: El hemoperitoneo secundario a rotura de un carcinoma hepatocelular, es una complicación poco frecuente, pero fatal; por lo que se hace necesario su estudio para lograr un diagnóstico y tratamiento oportuno(AU)

Introduction: Hepatocellular carcinoma is a hypervascular tumor made up of abnormal blood vessels. It is the most frequent form of primary liver cancer. About 90 percent of these tumors develop over a previous liver disease. An increase in vascular load due to portal hypertension leads to bleeding. Objective: To present a patient who underwent emergency exploratory laparotomy due to large hemoperitoneum secondary to an intratumoral rupture of a cirrhotic liver. Clinical case: A 66-year-old male patient with a pathological history of type 2 diabetes mellitus, benign prostatic hyperplasia, chronic alcoholism and liver cirrhosis. He came to emergency due to diffuse abdominal pain, as well as signs of acute hypovolemia. An emergency laparotomy was performed, confirming a large hemoperitoneum secondary to an intratumoral rupture. Blood content aspiration, electrocoagulation and compression by packing were performed, managing to control bleeding. He had a torpid evolution, dying 24 hours after the laparotomy. Conclusions: Hemoperitoneum secondary to rupture of a hepatocellular carcinoma is a rare, but fatal complication; therefore, its study is necessary to achieve a timely diagnosis and treatment(AU)

Lipossarcoma pleomórfico esplênico primário em uma cadela / Primary splenic pleomorphic liposarcoma in a bitch

Background: Liposarcoma is a malignant neoplasm of lipoblasts with low incidence in dogs, representing 1.7% of tumorsdiagnosed in the spleen. In veterinary medicine, this neoplasm is classified morphologically into the myxoid, well-differentiated, undifferentiated and pleomorphic subtypes, the latter being one of the most aggressive forms, mainly in cavityorgans. This report refers to a primary splenic pleomorphic liposarcoma in a female dog, addressing anatomopathologicaland immunohistochemical aspects.Case: A 14-year-old, 35 kg bitch mongrel with history of absence of defecation, progressive weight loss, difficulty walking, sensitivity to abdominal palpation, prostration, pale mucous membranes, tachypnea and abdominal distention waspresented to diagnosis. The condition evolved to death and, on necroscopy, there was an increase in splenic volume withneoformation of whitish and reddish color, measuring 32 × 27 cm in its largest axes and weighing 8.9 kg. The neoformationexhibited areas of firm and soft consistency, and sectioning revealed focal areas of extensive necrosis and cavity collectionsof different diameters that allowed the flow of liquid serous contents with a brownish red color. Microscopy showed cellsof neoplastic morphology infiltrating the splenic parenchyma, mostly with slightly acidophilic cytoplasm and few intracytoplasmic lipid vacuoles, which varied in size and distribution. The nucleus of the cells was large, eccentric and irregular,with round to oval morphology, grossly lacy chromatin and single or multiple evident nucleoli. These cells exhibited markedanisocytosis, anisokaryosis and pleomorphism, with more than one mitotic figure per high magnification field visible. Mildinflammatory infiltrate, predominantly lymphocytic, permeated the neoplastic cells, and marked depletion of lymphoidfollicles and atrophy of the red pulp were found in the remaining splenic parenchyma. Immunohistochemical tests...(AU)

Novel Method of Calculating Pulse Pressure Variation to Predict Fluid Responsiveness to Transfusion in Very Low Birth Weight Infants.

A novel technique was used to calculate pulse pressure variation. The algorithm reliably predicted fluid responsiveness to transfusion, with a receiver operating characteristic area under the curve of 0.89. This technique may assist clinicians in the management of fluids and vasoactive medications for premature infants.

Lipossarcoma pleomórfico esplênico primário em uma cadela / Primary splenic pleomorphic liposarcoma in a bitch

Background: Liposarcoma is a malignant neoplasm of lipoblasts with low incidence in dogs, representing 1.7% of tumorsdiagnosed in the spleen. In veterinary medicine, this neoplasm is classified morphologically into the myxoid, well-differentiated, undifferentiated and pleomorphic subtypes, the latter being one of the most aggressive forms, mainly in cavityorgans. This report refers to a primary splenic pleomorphic liposarcoma in a female dog, addressing anatomopathologicaland immunohistochemical aspects.Case: A 14-year-old, 35 kg bitch mongrel with history of absence of defecation, progressive weight loss, difficulty walking, sensitivity to abdominal palpation, prostration, pale mucous membranes, tachypnea and abdominal distention waspresented to diagnosis. The condition evolved to death and, on necroscopy, there was an increase in splenic volume withneoformation of whitish and reddish color, measuring 32 × 27 cm in its largest axes and weighing 8.9 kg. The neoformationexhibited areas of firm and soft consistency, and sectioning revealed focal areas of extensive necrosis and cavity collectionsof different diameters that allowed the flow of liquid serous contents with a brownish red color. Microscopy showed cellsof neoplastic morphology infiltrating the splenic parenchyma, mostly with slightly acidophilic cytoplasm and few intracytoplasmic lipid vacuoles, which varied in size and distribution. The nucleus of the cells was large, eccentric and irregular,with round to oval morphology, grossly lacy chromatin and single or multiple evident nucleoli. These cells exhibited markedanisocytosis, anisokaryosis and pleomorphism, with more than one mitotic figure per high magnification field visible. Mildinflammatory infiltrate, predominantly lymphocytic, permeated the neoplastic cells, and marked depletion of lymphoidfollicles and atrophy of the red pulp were found in the remaining splenic parenchyma. Immunohistochemical tests...

Neuropatía óptica asociada con lesión de Dieulafoy / Optic neuropathy associated with a Dieulafoy´s lesion

Objetivo: describir el caso de un paciente del Hospital de San José de Bogotá con hemorragia del tracto digestivo superior secundaria a lesión de Dieulafoy, que presentó cuadro compatible con neuropatía óptica anterior isquémica no arterítica (NOIANA). Metodología: se hace una revisión narrativa y búsqueda sistemática de la literatura para determinar las características clínicas, demográficas, tratamiento y pronóstico visual de los pacientes con NOIANA. Materiales y métodos: reporte de caso, revisión narrativa y búsqueda sistemática de la literatura en las bases de datos Medline (vía Ovid) y Embase de NOIANA secundaria a hipovolemia. Se analizaron las variables sociodemográficas, clínicas, diagnóstico, condiciones asociadas, tratamiento y pronóstico visual. El análisis estadístico se realizó mediante frecuencias absolutas y relativas. Resultados: la mejoría de agudeza visual final en los pacientes que presentaron un episodio de NOIANA es incierta. En 42% hubo algún tipo de mejoría de la agudeza visual, independiente del tratamiento recibido. Menos del 50% de los casos clínicos reportados incluidos en este estudio que recibieron tratamiento con corticoides intravenosos mejoraron la visión. Discusión: la NOIANA por choque hipovolémico es una entidad infrecuente y poco reportada que puede generar cambios irreversibles en la agudeza visual, por lo que es importante sospecharla y detectarla para dar un manejo oportuno. Conclusión: este caso de NOIANA es uno de los pocos descritos como secundarios a hemorragia digestiva y el primero asociado con lesión de Dieulafoy.

Objetive: to describe the case of a patient from Hospital de San José in Bogotá with upper gastrointestinal tract bleeding secondary to a Dieulafoy ́s lesion, who presented symptoms compatible with a non-arteritic anterior ischemic optic neuropathy (NA-AION). Methodology: a narrative review and systemic search of the literature was conducted to determine the clinical and demographic characteristics, treatment and visual prognosis in patients with NA-AION. Materials and methods: case report, narrative review and systematic search of the literature in Medline via Ovid and Embase databases on NA-AION secondary to hypovolemia. Sociodemographic and clinical variables, diagnosis, associated conditions, treatment and visual prognosis were analyzed. A statistical analysis was performed using absolute and relative frequencies. Results: improvement of final visual acuity in patients who presented a NA-AION episode was uncertain. In 42% there was some kind of visual acuity improvement regardless of treatment received. Vision improved in less than 50% of the reported clinical cases included in this study that received treatment with intravenous steroids. Discussion: hypovolemic NA-AION is a rare and underreported entity that may generate irreversible changes in visual acuity, so it is important to suspect and detect it to provide timely management. Conclusion: this case of NA-AION is one of the few described as secondary to gastrointestinal bleeding and the first associated with a Dieulafoy ́s lesion.

Anestesia intravenosa en urgencia / Total intravenous anesthesia in emergency

In emergency settings, TIVA should be adjusted in accordance to the pharmacological changes observed in the hypovolemic patient. With the understanding that in those cases there is a decrease in drug requirements, there is a tendency to underdose these patients, increasing the possibility of awareness. Variation in central volume concentration and blood flow redistribution increase plasma drug concentration (Cp). Decreased liver and kidney perfusion, hemodilution and hypothermia, all affect metabolism and clearance of drugs. Changes in drug bioavailability are also observed secondary to changes in plasma protein concentration and acidosis. Changes in pharmacodynamic of target organs are the product of metabolic and temperature disturbances. Due to the nature of hypovolemic shock, most systematic studies have been done in animals. In this condition, the volume of distribution and clearance of fentanyl decreases, increasing decremental times hence requiring bolus and infusion adjustment. Similar changes are observed when using remifentanil, but in this case its contextual half-life is not altered. In the case of etomidate use, most changes are observed on V2 and V3, with a minimal pharmacodynamic variation is observed, thus, requiring no adjustment. When propofol is used, the increase in Cp is proportional to the degree of hypovolemia, adding an increased sensitivity when it reaches over 40%. Data fit to the Eleveld's model (from animal data extrapolation) and simulations in TIVA trainer are shown. Experience shows that these suggestions overestimate the dose, especially within the first 10 minutes. Therefore, it is recommended to reduce the target by 50% in the case of crystalloid-based resuscitation and by 20% when colloids are preferred. Finally, ketamine has been repositioned as an analgesic drug, and is not recommended as a hypnotic, except when used with propofol or benzodiazepines. For propofol, a staggered induction is recommended (together with remifentanil and a neuromuscular blocker), maintaining then the concentration at the site of effect with which the unconsciousness was achieved. The use of EEG monitoring will yield a better titration.

En escenarios de urgencia, la TIVA se debe ajustar a los cambios farmacológicos observados en el paciente hipovolémico. En el entendido de que los requerimientos de drogas bajan, se tiende a subdosificar y con ello, aumentar la posibilidad de recuerdo intraoperatorio. La concentración del volumen central y la redistribución de flujo, aumentan la concentración plasmática (Cp) de droga. La disminución del flujo hepático y renal, la hemodilución y la hipotermia afectan el metabolismo y la distribución de las drogas. Cambios en la biodisponibilidad de drogas también se observan secundario a cambios en la concentración de proteínas plasmáticas y acidosis. Cambios farmacodinámicos de los órganos blancos son producto de las alteraciones metabólicas y de temperatura. Por la naturaleza del hipovolémico, los estudios sistemáticos han sido fundamentalmente en animales. El volumen de distribución y aclaramiento del fentanilo disminuyen, aumentando los tiempos decrementales. Requiere ajuste de bolo e infusión. Los mismos cambios se observan en el remifentanilo, sin embargo, su vida media contextual no se altera. Para etomidato se observa una contracción centrada en V2 y V3 y una variación farmacodinámica mínima, por lo que no requiere ajuste. Con propofol el aumento de la Cp es proporcional a la hipovolemia, agregándose aumento de la sensibilidad cuando es mayor del 40%. Se muestran ajustes basados en el modelo de Eleveld (de la extrapolación de datos animales) y simulaciones en TIVAtrainer. La experiencia muestra que estas sugerencias sobrestiman la dosis, especialmente los primeros 10 minutos, por lo que se aconseja disminuir el target en 50% en el caso de la reanimación basada en cristaloides y en 20% cuando se prefieren coloides. Por último, la ketamina se ha reposicionado como droga analgésica, no se recomienda como hipnótico, salvo en presencia de propofol o benzodiacepinas. Para propofol, se recomienda una inducción escalonada (junto con remifentanilo y un bloqueador neuromuscular), manteniendo luego con la concentración en en el sitio de efecto (Ce) con la que se alcanzó el LOC. El monitoreo con EEG permitirá una mejor titulación.

Vena cava inferior como factor predictor del shock en trauma: medición ecográfica / Inferior vena cava as a predictor of shock in trauma patients: sonographic measurement

Resumen Objetivo Establecer la medición ecográfica del diámetro de la vena cava inferior como factor predictor del shock en pacientes politraumatizados. Materiales y Método Estudio de corte transversal donde se determinó la medición ecográfica de la vena cava inferior a 40 pacientes que ingresaron a la Unidad de Politraumatizados (UPT) del Hospital General del Este "Dr. Domingo Luciani", en el período entre enero y abril de 2018. Se seleccionaron 2 grupos; el grupo 1: pacientes en shock , aquellos con tensión arterial sistólica menor a 90 mm Hg al ingreso, y el grupo 2: pacientes controles que mantuvieron cifras tensionales normales. El estudio de imagen de la vena cava inferior se realizó con el equipo de ecografía ALOKA prosound SSD-a5 y con el ultrasonido portátil MicroMaxx SonoSite , en el cual se midió el índice de colapsabilidad. Los hallazgos se registraron en la hoja de recolección de datos. El análisis estadístico se hizo con la prueba de t de student para muestras independientes y la valoración de puntos de corte diagnóstico se hizo con la prueba de ROC. Resultados La media del Índice de colapsabilidad (IC) de la VCI para el grupo control y de shock fue de 26 ± 12,7% y de 58,5 ± 5,9%, respectivamente; El índice de colapsabilidad fue > 50% en todos los pacientes del grupo de shock . Conclusiones La medición del diámetro de la VCI es un predictor de shock , siendo el IC el parámetro más sensible y específico.

Aim To establish the sonographic measurement of the diameter of the inferior vena cava as a predictor of shock in trauma patients. Materials and Method A cross-sectional study to determined the sonographic measurement of the inferior vena cava to 40 patients attended at Hospital Domingo Luciani trauma unit, in the period between January and April of 2018. Two groups were selected; group 1: shock patients, those with systolic blood pressure lower than 90 mm Hg, and the group 2: control patients that kept normal blood pressure. The image study of the inferior vena cava was carried out with the ALOKA prosound ultrasound equipment SSD a5 and with the portable ultrasound MicroMaxx SonoSite, in which the collapsibility index was measured. The findings were recorded in the data collection sheet. The statistical analysis proposed for the comparison of averages was made with the student's t-test for independent samples and the assessment of diagnostic cut-off points was made with a ROC curve. Results the mean of collapsability index of de IVC for control and shock group were 26 ± 12,7% and 58,5 ± 5,9%, respectively; The collapsability index (CI) was > 50% in all patients of shock group. Conclusions The measurement of the ICV diameter is a predictor of shock, being the IC the most sensitive and specific parameter.

Utilidad de la ecocardiografía transtorácica focalizada en emergencias hemodinámicas intraoperatorias / Usefulness of Focalized transthoracic ecocardiography in intraoperative hemodynamic emergencys

INTRODUCTION: Echocardiography represents one of the most important advances in the monitoring of critical patients. Initially available only in cardiovascular surgery, currently, there is transesophageal echocardiography (TEE) and transthoracic echocardiography (ETT) in non-cardiac surgery, for anesthesiologists. The advantages of ETT is a non-invasive tool, of lower cost than the transesophageal transducer and therefore more feasible to be overcrowded and available in the pavilion. OBJECTIVE: To evaluate the usefulness of TTE in patients with hemodynamic compromise during non-cardiac surgery. NATERIAL AND METHODS: In a prospective manner between April 2016 and September 2018, patients were studied who during their intraoperative period presented a compromise of their hemodynamic state, defined as an average blood pressure under 55 mm Hg, for more than 3 minutes and without response to the usual therapy based on vasopressors and volume. Each of these patients had a prospective protocol for focused ETT looking for the cause of this disorder, by a duly trained operator. RESULTS: 124 patients, with an average age of 67 years (range 42 to 93 years) were evaluated. In all cases, at least one echocardiographic window was obtained that allowed a diagnosis to be made and/or to guide the therapy. The main causes of hemodynamic compromise were hypovolemia (52%), poor left ventricular function (21%) and other causes such as pericardial effusion, suspected pulmonary thromboembolism, pulmonary pathology and suspected myocardial ischemia. DISCUSSION: The ETT could be a feasible tool to use in acute hemodynamic events, since it offers good quality windows that allow new decisions based on the diagnosis and also allows to guide the selected therapies. In addition, it has been shown to positively impact clinical behaviors in the perioperative period. ETT is a non-invasive monitor, reasonably easy to learn to use; In addition to directly visualizing cardiac structures, it allows differential diagnoses of the causes of intraoperative hypotension. The therapies can also be decided according to the echocardiographic images and control how they generate changes in the cardiac cavities and in the hemodynamic state of the patient.

INTRODUCCIÓN: La ecocardiografía representa uno de los más importantes avances en la monitorización de pacientes críticos. Inicialmente disponible sólo en cirugía cardiovascular, en la actualidad, se cuenta con ecocardiografía transesofágica (ETE) y ecocardiografía transtorácica (ETT) en cirugía no cardíaca, para los anestesiólogos. Las ventajas del ETT están en ser una herramienta no invasiva, de menor costo que el transductor transesofágico y, por lo tanto, más factible de ser masificada y estar disponible en pabellón. OBJETIVO: Evaluar la utilidad de ETT en pacientes con compromiso hemodinámico durante cirugía no cardiaca. MATERIAL Y MÉTODOS: En forma prospectiva entre abril de 2016 y septiembre del 2018, se estudiaron enfermos que durante su intraoperatorio presentaron compromiso de su estado hemodinámico, definido como una presión arterial media bajo 55 mm Hg, por más de 3 minutos y sin respuesta a la terapia habitual basada en vasopresores y volumen. A cada uno de estos enfermos se le realizó un protocolo prospectivo de ETT focalizado buscando la causa de esta alteración, por un operador debidamente entrenado. RESULTADOS: 124 pacientes, con edad promedio de 67 años (rango 42 a 93 años) fueron evaluados. En todos los casos se obtuvo al menos una ventana ecocardiográfica que permitió realizar un diagnóstico y/o guiar la terapia. Las principales causas de compromiso hemodinámico fueron hipovolemia (52%), mala función del ventrículo izquierdo (21%) y otras causas como derrame pericárdico, sospecha de tromboembolismo pulmonar, patología pulmonar y sospecha de isquemia miocárdica. La ETT podría ser una herramienta factible de utilizar en eventos hemodinámicos agudos, ya que ofrece ventanas de buena calidad que permiten tomar decisiones nuevas basadas en el diagnóstico y, además, permite guiar las terapias seleccionadas. Además, ha mostrado impactar de forma positiva las conductas clínicas en el perioperatorio. DISCUSIÓN: La ETT es un monitor no invasivo, razonablemente fácil de aprender a utilizar que además de visualizar de manera directa las estructuras cardíacas, permite realizar diagnósticos diferenciales de las causas de hipotensión intraoperatoria. Además, se puede decidir las terapias de acuerdo a las imágenes ecocardiográficas y controlar cómo éstas generan cambios en las cavidades cardíacas y en el estado hemodinámico del paciente.

Hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs dehydrated by water restriction: Part 1 / Soluções eletrolíticas enterais hipotônicas administradas por sonda nasoesofágica em fluxo contínuo em cães desidratados por restrição hídrica: Parte 1

The present study assessed and compared the effects of hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs submitted to water restriction on packed cell volume; total serum protein and serum osmolarity concentrations; blood volume; plasma glucose and lactate levels; blood gas analysis, anion gap, and strong ion difference. Six adult dogs were used (four males and two females). All animals were submitted to both proposed treatments in a crossover design 6×2. The treatments were as follows: ESmalt consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g maltodextrin that were diluted in 1.000mL water (measured osmotic concentration of 215mOsm L−1) and ESdext consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g dextrose that were diluted in 1.000mL water (measured osmotic concentration of 243mOsm L−1). All solutions were administered at 15ml kg−1 h−1 for 4 hours. Both solutions increased the plasma volume in dehydrated dogs without causing adverse effects. However, ESmalt was more effective in promoting the increase in blood volume.(AU)

O presente estudo avaliou e comparou os efeitos de soluções eletrolíticas enterais hipotônicas, administradas por sonda nasoesofágica em fluxo contínuo em cães submetidos a restrição hídrica, sobre o hematócrito, proteínas totais séricas, osmolaridade sérica, volemia, glicose e lactato plasmáticos, hemogasometria, ânion gap e DIF. Foram utilizados seis cães adultos (quatro machos e duas fêmeas). Todos os animais foram submetidos aos dois tratamentos propostos, em um delineamento crossover 6×2. Os tratamentos foram os seguintes: SEmalt - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de maltodextrina, diluídos em 1.000mL de água (osmolaridade mensurada: 215mOsm L -1 ); SEdext - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de dextrose, diluídos em 1.000mL de água (osmolaridade mensurada: 243mOsm L -1 ). Todas as soluções foram administradas no volume de 15mL kg -1 hora -1 , durante quatro horas, em fluxo contínuo. Ambas as soluções aumentaram o volume plasmático em cães desidratados, sem gerar o aparecimento de efeitos adversos. Porém, a SEmalt foi mais eficaz em promover a expansão da volemia.

Hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs dehydrated by water restriction: Part 1 / Soluções eletrolíticas enterais hipotônicas administradas por sonda nasoesofágica em fluxo contínuo em cães desidratados por restrição hídrica: Parte 1

The present study assessed and compared the effects of hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs submitted to water restriction on packed cell volume; total serum protein and serum osmolarity concentrations; blood volume; plasma glucose and lactate levels; blood gas analysis, anion gap, and strong ion difference. Six adult dogs were used (four males and two females). All animals were submitted to both proposed treatments in a crossover design 6×2. The treatments were as follows: ESmalt consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g maltodextrin that were diluted in 1.000mL water (measured osmotic concentration of 215mOsm L−1) and ESdext consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g dextrose that were diluted in 1.000mL water (measured osmotic concentration of 243mOsm L−1). All solutions were administered at 15ml kg−1 h−1 for 4 hours. Both solutions increased the plasma volume in dehydrated dogs without causing adverse effects. However, ESmalt was more effective in promoting the increase in blood volume.(AU)

O presente estudo avaliou e comparou os efeitos de soluções eletrolíticas enterais hipotônicas, administradas por sonda nasoesofágica em fluxo contínuo em cães submetidos a restrição hídrica, sobre o hematócrito, proteínas totais séricas, osmolaridade sérica, volemia, glicose e lactato plasmáticos, hemogasometria, ânion gap e DIF. Foram utilizados seis cães adultos (quatro machos e duas fêmeas). Todos os animais foram submetidos aos dois tratamentos propostos, em um delineamento crossover 6×2. Os tratamentos foram os seguintes: SEmalt - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de maltodextrina, diluídos em 1.000mL de água (osmolaridade mensurada: 215mOsm L -1 ); SEdext - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de dextrose, diluídos em 1.000mL de água (osmolaridade mensurada: 243mOsm L -1 ). Todas as soluções foram administradas no volume de 15mL kg -1 hora -1 , durante quatro horas, em fluxo contínuo. Ambas as soluções aumentaram o volume plasmático em cães desidratados, sem gerar o aparecimento de efeitos adversos. Porém, a SEmalt foi mais eficaz em promover a expansão da volemia.

Descrição da prática do uso da vasopressina em recém-nascidos internados em uti neonatal / Description of the use of vasopressin in newborns admitted to a neonatal intensive care unit

A hipotensão arterial sistêmica é uma complicação comum na UTI neonatal e quando é refratária ao tratamento inicial com volume (nos casos de hipovolemia), catecolaminas ou corticosteróides tem taxa de mortalidade alta. A vasopressina se apresenta como tratamento a essa situação de hipotensão refratária. Este trabalho objetivou descrever a prática de utilização da vasopressina no tratamento de hipotensão refratária ao uso de aminas vasoativas em recém-nascidos internados em uma UTI neonatal.Foi realizado um estudo retrospectivo, com a coleta de dados dos prontuários dos recém-nascidos que fizeram uso dessa medicação dejaneiro de 2012 até janeiro 2018. Como resultado, foram analisados 80 prontuários, 64 de pacientes prematuros, 14 pacientes a termo e 2 pós-termo, com peso médio geral de 1375g. Foi encontrada uma associação estatística significativa entre sobrevida e o tempo de uso da vasopressina por menos do que 1 semana, aumento de no mínimo 30% da pressão arterial média nas primeiras 6 horas após o início da vasopressina e ausência de anúria ao se iniciar a vasopressina.

Systemic arterial hypotension is a common complication in the neonatal ICU and when it is refractory to initial treatment with volume (in cases of hypovolemia), catecholamines or corticosteroids have a high mortality rate. Vasopressin presents as a treatment for this situation of refractory hypotension. This study aimed to describe the use of vasopressin in the treatment of refractory hypotension to the vasoactive amines in neonates admitted in a neonatal intensive care unit. We retrospectivelyanalysed data from newborns that used this medication from January 2012 until January 2018. 80 charts were analyzed, (64 of preterm, 14 full-term and 2 post-term patients) with mean weight of 1375g. A statistically significant association was found between survival and duration of use of vasopressin for less than 1 week, increase of at least 30% of mean arterial pressure within the first 6 hours after vasopressin onset and absence of anuria upon initiation of vasopressin.

Gestação e queimadura: experiência de unidade de queimaduras em Hospital Universitário / Pregnancy and burns: experience of a university hospital burn unit

Introdução: A incidência de queimaduras em gestantes não é bem estabelecida na literatura mundial, mas estima-se que varie entre 3% e 7%. Os cuidados da gestante queimada representam um grande desafio com impacto significante nos resultados e prognóstico materno-fetais. Relato de Caso: No presente estudo relatamos dois casos de gestantes vítimas de queimaduras que foram tratadas na unidade de tratamento de queimaduras na Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM/UNIFESP), uma no primeiro trimestre e a outra no terceiro trimestre. Conclusão: Em ambos os casos, as gestantes receberam tratamento especializado para queimaduras em conjunto com acompanhamento clínico da equipe da obstetrícia, com boa evolução materno-fetal.

Introduction: The incidence of burns involving pregnant women is not well established in the literature, but is estimated to be between 3% and 7%. The management of burns in pregnancy represents a great challenge with significant impact on outcomes and maternal-fetal prognosis. Case Report: In the present study, we report two cases of pregnant burn victims who were treated in the burn unit in the Paulista School of Medicine, Federal University of São Paulo (EPM/UNIFESP). One patient was treated in the first trimester and the other in the third trimester. Conclusion: In both cases, the pregnant women received specialized treatment for burns in conjunction with clinical follow-up by the obstetrics team, with good maternal-fetal outcomes.

Clinical responses to acute blood loss in goats / Respostas clínicas à perda sanguínea aguda em caprinos

The response to blood loss is directly related to the degree of hemorrhage, but for the caprine species some aspects still need to be investigated. Therefore, the present study aimed to assess the clinical and hemodynamic effects of acute blood loss in goats. Eight healthy, adult male crossbred goats were subjected to external jugular puncture to remove 30% of the total blood volume. A physical examination and blood gas, biochemical, and hematologic analyses were performed at baseline, before blood loss (T0), and after one (T1h), six (T6h), 12 (T12h), 24 (T24h) and 72 (T72h) hours, and eight (T8d), 16 (T16d), 24 (T24d) and 32 (T32d) days after the acute blood loss event. The goats presented with tachycardia, tachypnea, and hyperthermia one hour after blood loss with a return to normal physiological values at T6h. Packed cell volume was decreased at T1h and red cell counts at T12h, both returning to baseline at T24d. There was a reduction in total protein and albumin levels at T1h, both remained below baseline levels until T16d and T8d, respectively. The serum calcium concentration decreased over the period T1h to T24h and glucose increased over the period T1h to T6h. The values of pH, TCO2 , bicarbonate, and base excess were lower at T1h, while lactate increased markedly at this time. The pCO2 value only was reduced at T24h. Systolic (PS), diastolic (PD), and mean (PM) pressures were decreased at T1h. Acute loss of 30% of blood volume in goats caused changes in clinical, blood gas, and biochemical parameters, which were restored over a six-hour period, while hematologic changes were more persistent, with baseline values restored only after 24 days.

A resposta clínica à perda de sangue está diretamente relacionada ao grau de hemorragia, mas para a espécie caprinas alguns aspectos ainda precisam ser investigados. Deste modo o presente estudo teve como objetivo avaliar os efeitos clínicos e hemodinâmicos da perda aguda de sangue em caprinos. Oito caprinos adultos, mestiços, hígidos, foram submetidas a punção jugular externa para remoção de 30% do volume total de sangue. Foi realizado exame clínico e análises hematológicas, hemogasométricas e bioquímicas no momento basal, antes da perda de sangue (T0), e uma (T1h), seis (T6h), 12 (T12h), 24 (T24h) e 72 (T72h) horas e oito (T8d), 16 (T16d), 24 (T24d) e 32 (T32d) dias após. As cabras apresentaram taquicardia, taquipneia e hipertermia uma hora após a perda de sangue com retorno aos valores fisiológicos em T6h. O volume globular diminuiu em T1h e a contagem de células vermelhas em T12h, ambos retornando valores basais em T24d. Houve uma redução nos níveis de proteína totais e albumina em T1h, e ambos permaneceram abaixo dos níveis basais até T16d e T8d, respectivamente. A concentração sérica de cálcio diminuiu durante o período T1h para T24h e a glicose aumentou no período T1h a T6h. Os valores de pH, TCO2, bicarbonato e excesso de base foram menores em T1h, enquanto o lactato aumentou acentuadamente neste momento. O pCO2 foi reduzida somente em T24h. As pressões sistólica (PS), diastólica (PD) e média (PM) diminuíram em T1h. A perda aguda de 30% do volume sangüíneo em cabras causou alterações nos parâmetros clínicos, hemogasométricos e bioquímicos, que foram restaurados ao longo de um período de seis horas, enquanto que as alterações hematológicas foram mais persistentes, com valores basais restaurados somente após 24 dias.

Clinical responses to acute blood loss in goats / Respostas clínicas à perda sanguínea aguda em caprinos

The response to blood loss is directly related to the degree of hemorrhage, but for the caprine species some aspects still need to be investigated. Therefore, the present study aimed to assess the clinical and hemodynamic effects of acute blood loss in goats. Eight healthy, adult male crossbred goats were subjected to external jugular puncture to remove 30% of the total blood volume. A physical examination and blood gas, biochemical, and hematologic analyses were performed at baseline, before blood loss (T0), and after one (T1h), six (T6h), 12 (T12h), 24 (T24h) and 72 (T72h) hours, and eight (T8d), 16 (T16d), 24 (T24d) and 32 (T32d) days after the acute blood loss event. The goats presented with tachycardia, tachypnea, and hyperthermia one hour after blood loss with a return to normal physiological values at T6h. Packed cell volume was decreased at T1h and red cell counts at T12h, both returning to baseline at T24d. There was a reduction in total protein and albumin levels at T1h, both remained below baseline levels until T16d and T8d, respectively. The serum calcium concentration decreased over the period T1h to T24h and glucose increased over the period T1h to T6h. The values of pH, TCO2 , bicarbonate, and base excess were lower at T1h, while lactate increased markedly at this time. The pCO2 value only was reduced at T24h. Systolic (PS), diastolic (PD), and mean (PM) pressures were decreased at T1h. Acute loss of 30% of blood volume in goats caused changes in clinical, blood gas, and biochemical parameters, which were restored over a six-hour period, while hematologic changes were more persistent, with baseline values restored only after 24 days.(AU)

A resposta clínica à perda de sangue está diretamente relacionada ao grau de hemorragia, mas para a espécie caprinas alguns aspectos ainda precisam ser investigados. Deste modo o presente estudo teve como objetivo avaliar os efeitos clínicos e hemodinâmicos da perda aguda de sangue em caprinos. Oito caprinos adultos, mestiços, hígidos, foram submetidas a punção jugular externa para remoção de 30% do volume total de sangue. Foi realizado exame clínico e análises hematológicas, hemogasométricas e bioquímicas no momento basal, antes da perda de sangue (T0), e uma (T1h), seis (T6h), 12 (T12h), 24 (T24h) e 72 (T72h) horas e oito (T8d), 16 (T16d), 24 (T24d) e 32 (T32d) dias após. As cabras apresentaram taquicardia, taquipneia e hipertermia uma hora após a perda de sangue com retorno aos valores fisiológicos em T6h. O volume globular diminuiu em T1h e a contagem de células vermelhas em T12h, ambos retornando valores basais em T24d. Houve uma redução nos níveis de proteína totais e albumina em T1h, e ambos permaneceram abaixo dos níveis basais até T16d e T8d, respectivamente. A concentração sérica de cálcio diminuiu durante o período T1h para T24h e a glicose aumentou no período T1h a T6h. Os valores de pH, TCO2, bicarbonato e excesso de base foram menores em T1h, enquanto o lactato aumentou acentuadamente neste momento. O pCO2 foi reduzida somente em T24h. As pressões sistólica (PS), diastólica (PD) e média (PM) diminuíram em T1h. A perda aguda de 30% do volume sangüíneo em cabras causou alterações nos parâmetros clínicos, hemogasométricos e bioquímicos, que foram restaurados ao longo de um período de seis horas, enquanto que as alterações hematológicas foram mais persistentes, com valores basais restaurados somente após 24 dias.(AU)