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1.
Rev Cardiovasc Med ; 21(2): 297-301, 2020 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-32706217

RESUMO

Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism. Bradycardia is a well-known cardiac manifestation for myxedema coma; however, not all bradycardia with hypothyroidism are sinus bradycardia. Sick sinus syndrome is a group of arrhythmias caused by the malfunction of the natural pacemaker of the heart. Tachy-Brady syndrome is considered to be a type of sick sinus syndrome, where the heart alternates between tachycardia and bradycardia, and it is usually treated with pacemaker implantation along with rate slowing medical therapy. Here we report a case of an 83-year-old female who presented with myxedema coma and atrial fibrillation with tachycardia and intermittent slow ventricular response. We attempt to review the relationship between these two diseases and conclude that appropriate diagnosis of myxedema coma, may be beneficial in reducing the need for pacemaker implantation.


Assuntos
Bradicardia/etiologia , Coma/etiologia , Frequência Cardíaca , Hipotireoidismo/complicações , Mixedema/etiologia , Idoso de 80 Anos ou mais , Bradicardia/diagnóstico , Bradicardia/fisiopatologia , Bradicardia/terapia , Estimulação Cardíaca Artificial , Coma/diagnóstico , Coma/tratamento farmacológico , Coma/fisiopatologia , Feminino , Frequência Cardíaca/efeitos dos fármacos , Terapia de Reposição Hormonal , Humanos , Hipotireoidismo/diagnóstico , Hipotireoidismo/tratamento farmacológico , Hipotireoidismo/fisiopatologia , Mixedema/diagnóstico , Mixedema/tratamento farmacológico , Mixedema/fisiopatologia , Índice de Gravidade de Doença , Tiroxina/uso terapêutico , Resultado do Tratamento
3.
Am J Emerg Med ; 38(5): 1044.e3-1044.e4, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31870671

RESUMO

Placement of a transvenous pacer is an important procedure mainly used to treat hemodynamically unstable brady-arrhythmias. In the Emergency Department (ED), wire placement into the right ventricle is typically performed blindly, or in some cases, under transthoracic ultrasound guidance. This case report describes a patient with extensive cardiac history who presented after a witnessed arrest, and after return of spontaneous circulation, sustained an unstable bradycardia requiring emergent transvenous pacer placement while in the ED. A temporary pacer wire was placed transvenously without successful capture. Transesophageal echocardiography was then utilized to guide and adjust the pacer wire placement helping to successfully achieve capture. To our knowledge, this is the first report to describe transesophageal echocardiogram-assisted placement of a transvenous pacer wire while in the ED.


Assuntos
Bradicardia/terapia , Cateterismo Cardíaco/métodos , Terapia de Ressincronização Cardíaca/métodos , Ventrículos do Coração/diagnóstico por imagem , Idoso de 80 Anos ou mais , Bradicardia/etiologia , Cateterismo Cardíaco/efeitos adversos , Terapia de Ressincronização Cardíaca/efeitos adversos , Ecocardiografia Transesofagiana , Eletrocardiografia , Serviço Hospitalar de Emergência , Feminino , Humanos , Marca-Passo Artificial
4.
Intern Med ; 58(21): 3099-3102, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31685785

RESUMO

A 30-year-old woman was referred to our hospital to undergo an evaluation for suspected Brugada syndrome. She showed no symptoms, but had a strong family history of sudden cardiac death. During observation, Holter electrocardiography (ECG), which had been performed to investigate her symptoms of occasional dizziness, showed a sinus node dysfunction with an occasional long sinus pause. An implantable cardioverter defibrillator (ICD) was therefore put in place, and bradycardia pacing from the ICD relieved those symptoms during the subsequent 18-month follow-up. The patient completed two pregnancies during the follow-up period. No symptomatic changes occurred during the pregnancies, but ECG indicated that an ST segment elevation in the right precordial leads was attenuated during the second and third trimesters of both pregnancies.


Assuntos
Síndrome de Brugada/terapia , Desfibriladores Implantáveis , Complicações Cardiovasculares na Gravidez/terapia , Adulto , Bradicardia/terapia , Síndrome de Brugada/diagnóstico , Morte Súbita Cardíaca , Eletrocardiografia , Eletrocardiografia Ambulatorial , Feminino , Humanos , Linhagem , Gravidez , Síndrome do Nó Sinusal/diagnóstico , Síndrome do Nó Sinusal/terapia
6.
Am J Case Rep ; 20: 1356-1359, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31515465

RESUMO

BACKGROUND It is still challenging to remove an epidural catheter in a postoperative patient receiving urgent antiplatelet and anticoagulation therapy for acute coronary syndrome. CASE REPORT While under general anesthesia combined with thoracic epidural anesthesia, a 72-year-old male patient underwent right radical nephrectomy for renal cell carcinoma. On postoperative day 1 (POD1), the patient experienced bradycardia and a decrease in blood pressure, and he was diagnosed acute myocardial infarction. Intra-aortic balloon pumping (IABP) was induced for cardiogenic shock, and urgent thrombus aspiration and coronary balloon angioplasty were performed. On POD3, the surgeon removed the epidural catheter under both antiplatelet and anticoagulation therapy. At that time, the platelet count was 45×109/L and the activated partial thromboplastin time (APTT) was 72.2 seconds. Four hours after the epidural catheter was removed, the patient complained of bilateral fatigue in legs and developed a loss of sensation. Six hours after the epidural catheter was removed, he developed motor paralysis and became completely paralyzed in both limbs after 9 hours. At 19 hours after the epidural catheter was removed, emergency magnetic resonance imaging detected a spinal epidural hematoma at the level of Th9-11 with compression of the spinal cord. Emergency laminectomy was performed to decompress and remove the spinal epidural hematoma at 18 hours after the onset of sensorimotor symptoms. After surgery and rehabilitation, these symptoms had only slightly improved. CONCLUSIONS In patients with urgent antithrombotic therapy for urgent percutaneous coronary intervention (PCI) with an IABP for acute coronary syndrome, the epidural catheter should not be removed until the IABP and heparin are discontinued, and platelet counts have recovered.


Assuntos
Anestesia Epidural/efeitos adversos , Angioplastia Coronária com Balão , Anticoagulantes/efeitos adversos , Hematoma Epidural Espinal/etiologia , Balão Intra-Aórtico , Infarto do Miocárdio/terapia , Idoso , Anestesia Geral , Anticoagulantes/administração & dosagem , Bradicardia/etiologia , Bradicardia/terapia , Trombose Coronária/terapia , Hematoma Epidural Espinal/diagnóstico por imagem , Hematoma Epidural Espinal/terapia , Humanos , Laminectomia , Imagem por Ressonância Magnética , Masculino , Infarto do Miocárdio/etiologia , Paralisia/etiologia , Paralisia/terapia , Complicações Pós-Operatórias , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/terapia , Trombectomia
7.
Curr Cardiol Rep ; 21(10): 127, 2019 09 13.
Artigo em Inglês | MEDLINE | ID: mdl-31520271

RESUMO

PURPOSE OF REVIEW: The goal of this paper is to review present knowledge regarding preventive and antitachycardia pacing algorithms, aimed to reduce atrial fibrillation (AF) burden in patients when pacing is indicated. RECENT FINDINGS: Reactive antitachycardia pacing (ATP), the new generation of ATP, is significantly associated with a reduced risk of AF. In patients with indication for pacing and history of AF, pacemakers endowed with atrial preventive pacing and atrial ATP combined with managed ventricular pacing proved superior to standard dual-chamber pacing. Managed ventricular pacing is an algorithm that minimizes unnecessary right ventricular pacing. Progression to persistent AF is prevented by ventricular pacing minimization in patients with normal PR interval. The synergistic effect of pacemakers that combine atrial preventive pacing with reactive ATP and with algorithms that minimize ventricular pacing can reduce AF incidence and decrease the combined endpoint of permanent AF, hospital admissions, and mortality.


Assuntos
Fibrilação Atrial/terapia , Bradicardia/terapia , Estimulação Cardíaca Artificial/métodos , Marca-Passo Artificial , Terapia Assistida por Computador/métodos , Algoritmos , Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Bradicardia/complicações , Bradicardia/mortalidade , Estimulação Cardíaca Artificial/efeitos adversos , Átrios do Coração , Humanos , Resultado do Tratamento
8.
Pediatr Pulmonol ; 54(11): 1742-1746, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31373180

RESUMO

Neurally adjusted ventilatory assistance (NAVA) can overcome technical difficulties with synchronizing noninvasive ventilation breaths with the patient, a modality often used in very low birthweight infants (VLBW) with apnea of prematurity (AOP). This study is a retrospective single-center investigation into whether NAVA-synchronized noninvasive (niNAVA) ventilation is better than nonsynchronized (nasal intermittent positive pressure ventilation [nIPPV]) for symptomatic apnea in VLBW infants. Nursing records of apnea, bradycardia, and/or desaturations were abstracted from the electronic medical records of 108 VLBW infants admitted to the neonatal intensive care unit (NICU) from 2015 to 2017 who received either of the two modalities, 61 epochs of niNAVA totaling 488 days and 103 epochs of nIPPV totaling 886.5 days. niNAVA was associated with a significant reduction in the number of isolated bradycardic events/day (0.48 ± 0.14 vs 1.35 ± 0.27; P = .019) and overall bradycardias/day (2.42 ± 0.47 vs 4.02 ± 0.53; P = .042) and there were more epochs with no events with niNAVA compared with nIPPV (23.0% vs 6.8%; P = .004). These results justify a prospective trial of NAVA-synchronized noninvasive ventilation for VLBW infants with caffeine-resistant AOP.


Assuntos
Apneia/terapia , Bradicardia/terapia , Suporte Ventilatório Interativo , Ventilação com Pressão Positiva Intermitente , Ventilação não Invasiva , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Unidades de Terapia Intensiva Neonatal , Masculino , Estudos Retrospectivos
9.
Med Clin North Am ; 103(5): 897-912, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31378333

RESUMO

In this article, the authors review the different types of sinus node and atrioventricular node diseases that lead to bradyarrhythmias with their associated symptoms, the diagnostic investigations needed to assess the degree of disease, and the therapeutic management, including the indications for permanent pacing.


Assuntos
Bradicardia/terapia , Estimulação Cardíaca Artificial/métodos , Humanos , Marca-Passo Artificial
10.
Med Clin North Am ; 103(5): 931-943, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31378335

RESUMO

Cardiac implantable electronic devices (CIEDs) provide lifesaving therapy for the treatment of bradyarrhythmias, ventricular tachyarrhythmias, and advanced systolic heart failure. Advances in CIED therapy have expanded the number of patients receiving permanent pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy devices. These devices improve quality of life and, in many cases, reduce mortality. However, limitations remain in the management of patients who require CIED therapy. This article provides a broad overview of CIED therapy in the management of the cardiac patient.


Assuntos
Bradicardia/terapia , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca Sistólica/terapia , Taquicardia Ventricular/terapia , Dispositivos de Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Humanos , Marca-Passo Artificial , Qualidade de Vida
12.
Neth J Med ; 77(5): 189-192, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31264585
13.
Dis Model Mech ; 12(7)2019 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-31208990

RESUMO

Mutations in GNB5, encoding the G-protein ß5 subunit (Gß5), have recently been linked to a multisystem disorder that includes severe bradycardia. Here, we investigated the mechanism underlying bradycardia caused by the recessive p.S81L Gß5 variant. Using CRISPR/Cas9-based targeting, we generated an isogenic series of human induced pluripotent stem cell (hiPSC) lines that were either wild type, heterozygous or homozygous for the GNB5 p.S81L variant. These were differentiated into cardiomyocytes (hiPSC-CMs) that robustly expressed the acetylcholine-activated potassium channel [I(KACh); also known as IK,ACh]. Baseline electrophysiological properties of the lines did not differ. Upon application of carbachol (CCh), homozygous p.S81L hiPSC-CMs displayed an increased acetylcholine-activated potassium current (I K,ACh) density and a more pronounced decrease of spontaneous activity as compared to wild-type and heterozygous p.S81L hiPSC-CMs, explaining the bradycardia in homozygous carriers. Application of the specific I(KACh) blocker XEN-R0703 resulted in near-complete reversal of the phenotype. Our results provide mechanistic insights and proof of principle for potential therapy in patients carrying GNB5 mutations.This article has an associated First Person interview with the first author of the paper.


Assuntos
Acetilcolina/farmacologia , Bradicardia/genética , Subunidades beta da Proteína de Ligação ao GTP/genética , Variação Genética , Canais de Potássio/efeitos dos fármacos , Receptores Colinérgicos/fisiologia , Animais , Bradicardia/terapia , Humanos , Células-Tronco Pluripotentes Induzidas/metabolismo , Mutação , Técnicas de Patch-Clamp , Canais de Potássio/fisiologia , Estudo de Prova de Conceito , Peixe-Zebra
14.
BMJ Case Rep ; 12(5)2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31151977

RESUMO

Ciguatera is a common but underreported tropical disease caused by the consumption of coral reef fish contaminated by ciguatoxins. Gastrointestinal and neurological symptoms predominate, but may be accompanied by cardiovascular features such as hypotension and sinus bradycardia. Here, we report an unusual case of junctional bradycardia caused by ciguatera in the Caribbean; to our knowledge, the first such report from the region. An increase in global sea temperatures is predicted to lead to the spread of ciguatera beyond traditional endemic areas, and the globalisation of trade in coral reef fish has resulted in sporadic cases occurring in developed countries far away from endemic areas. This case serves as a reminder to consider environmental intoxications such as ciguatera within the differential diagnosis of bradycardias.


Assuntos
Bradicardia/etiologia , Intoxicação por Ciguatera/complicações , Animais , Bradicardia/terapia , Região do Caribe , Intoxicação por Ciguatera/terapia , Soluções Cristaloides/administração & dosagem , Diagnóstico Diferencial , Eletrocardiografia , Peixes , Humanos , Masculino , Pessoa de Meia-Idade , Potássio/administração & dosagem
15.
Am J Case Rep ; 20: 748-752, 2019 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-31130721

RESUMO

BACKGROUND Acute pulmonary embolism (PE) is a common life-threatening cardiovascular emergency. The diagnosis of PE may be challenging, as there can be a wide range of atypical presentations. CASE REPORT A 92-year-old man with asymptomatic first-degree atrioventricular (AV) block, hypertension that was controlled on medication, and a past medical history of deep venous thrombosis (DVT), presented with dizziness, weakness, and collapse while getting dressed. On examination by the attending paramedics, he was noted to have sinus bradycardia at a rate of 18 bpm, which improved to 80 bpm after intravenous injection of atropine. An echocardiogram obtained in the emergency room (ER) showed a markedly dilated right ventricle (RV) with a hypokinetic RV free wall, preserved RV apical contractility, and septal wall motion abnormalities consistent with RV pressure overload. A ventilation/perfusion (V/Q) scan showed a massive PE involving more than 50% of the pulmonary vasculature. Urgent catheter-directed thrombolysis was performed, but the patient's condition deteriorated, and he died shortly afterward. CONCLUSIONS Sinus bradycardia is an unusual initial presentation of PE, but the diagnosis should be considered in patients with multiple risk factors for thromboembolism.


Assuntos
Bradicardia/etiologia , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico , Doença Aguda , Idoso de 80 Anos ou mais , Bradicardia/diagnóstico , Bradicardia/terapia , Evolução Fatal , Humanos , Masculino , Embolia Pulmonar/terapia
16.
Circ Arrhythm Electrophysiol ; 12(6): e007415, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31113233

RESUMO

Background His-bundle pacing (HBP) is a physiological form of pacing. Although high capture thresholds are common, few predictors of low HBP threshold have been determined. We aimed to identify electrophysiological predictors. Methods Fifty-one patients (53% with atrioventricular block) underwent HBP for bradycardia with an intrinsic QRS duration of <120 ms. Attempts to anchor the HBP lead were guided by unipolar His-bundle electrograms (HB EGMs) recorded with an electrophysiology recording system. Patients were followed-up for >6 months. Results In total, 153 attempts at anchoring the HBP lead were made, of which, 45 achieved acceptable HBP thresholds (≤2.5 V at 1 ms). The amplitude of negative deflection in HB EGM and the selective HBP form at fixation were independently associated with achieving an acceptable threshold. A negative amplitude of ≥0.060 mV in HB EGM was determined as the optimal value for identifying the acceptable threshold. This deep negative HB EGM was recorded with an HBP threshold of 1.4±1.3 V (in 34 attempts), significantly lower than that of positive HB EGM without deep negative deflection (2.8±1.3 V, in 31 trials; or >5 V, in 38 trials). The permanent HBP lead remained with deep negative (≥0.060 mV) or positive HB EGMs in 28 and 14 patients, respectively, and with positive or negative HB injury current in 19 and 23 patients, respectively. During follow-up, increased HBP threshold of >1 V was significantly more prevalent in the positive HB EGM group. The HBP thresholds of deep negative HB EGM and HB injury current, but not of the selective HBP group, were significantly lower than the other subgroups during follow-up. Conclusions Deep negative HB EGM at fixation was associated with an excellent short-term HBP threshold, similar to HB injury current. Analysis of unipolar HB EGM postfixation may enable prediction of permanent HBP threshold.


Assuntos
Potenciais de Ação , Bloqueio Atrioventricular/diagnóstico , Bloqueio Atrioventricular/terapia , Bradicardia/diagnóstico , Fascículo Atrioventricular/fisiopatologia , Estimulação Cardíaca Artificial , Técnicas Eletrofisiológicas Cardíacas , Frequência Cardíaca , Idoso , Idoso de 80 Anos ou mais , Bloqueio Atrioventricular/fisiopatologia , Bradicardia/fisiopatologia , Bradicardia/terapia , Estimulação Cardíaca Artificial/efeitos adversos , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
17.
Arq Bras Cardiol ; 112(4): 410-421, 2019 04.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30994720

RESUMO

BACKGROUND: Considering the potential deleterious effects of right ventricular (RV) pacing, the hypothesis of this study is that isolated left ventricular (LV) pacing through the coronary sinus is safe and may provide better clinical and echocardiographic benefits to patients with bradyarrhythmias and normal ventricular function requiring heart rate correction alone. OBJECTIVE: To assess the safety, efficacy, and effects of LV pacing using an active-fixation coronary sinus lead in comparison with RV pacing, in patients eligible for conventional pacemaker (PM) implantation. METHODS: Randomized, controlled, and single-blinded clinical trial in adult patients submitted to PM implantation due to bradyarrhythmias and systolic ventricular function ≥ 0.40. Randomization (RV vs. LV) occurred before PM implantation. The main results of the study were procedural success, safety, and efficacy. Secondary results were clinical and echocardiographic changes. Chi-squared test, Fisher's exact test and Student's t-test were used, considering a significance level of 5%. RESULTS: From June 2012 to January 2014, 91 patients were included, 36 in the RV Group and 55 in the LV Group. Baseline characteristics of patients in both groups were similar. PM implantation was performed successfully and without any complications in all patients in the RV group. Of the 55 patients initially allocated into the LV group, active-fixation coronary sinus lead implantation was not possible in 20 (36.4%) patients. The most frequent complication was phrenic nerve stimulation, detected in 9 (25.7%) patients in the LV group. During the follow-up period, there were no hospitalizations due to heart failure. Reductions of more than 10% in left ventricular ejection fraction were observed in 23.5% of patients in the RV group and 20.6% of those in the LV group (p = 0.767). Tissue Doppler analysis showed that 91.2% of subjects in the RV group and 68.8% of those in the LV group had interventricular dyssynchrony (p = 0.022). CONCLUSION: The procedural success rate of LV implant was low, and the safety of the procedure was influenced mainly by the high rate of phrenic nerve stimulation in the postoperative period.


Assuntos
Bradicardia/terapia , Estimulação Cardíaca Artificial/métodos , Ventrículos do Coração/fisiopatologia , Marca-Passo Artificial , Adulto , Idoso , Idoso de 80 Anos ou mais , Bradicardia/fisiopatologia , Estimulação Cardíaca Artificial/efeitos adversos , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial/efeitos adversos , Implantação de Prótese/métodos , Reprodutibilidade dos Testes , Método Simples-Cego , Volume Sistólico , Resultado do Tratamento , Adulto Jovem
18.
Circulation ; 140(5): 370-378, 2019 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-31006260

RESUMO

BACKGROUND: Cardiopulmonary resuscitation (CPR) is initiated in hospitalized children with bradycardia and poor perfusion. However, their rate of progression to pulseless cardiac arrest despite CPR and the differences in survival compared with initially pulseless arrest are unknown. We examined the prevalence and predictors of survival of children who progress from bradycardia to pulseless in-hospital cardiac arrest despite CPR. METHODS: Pediatric patients >30 days and <18 years of age who received CPR at hospitals participating in Get With The Guidelines-Resuscitation during 2000 to 2016 were included. Each CPR event was classified as bradycardia with pulse, bradycardia with subsequent pulselessness, and initial pulseless cardiac arrest. We assessed risk-adjusted rates of survival to hospital discharge using multilevel Poisson regression models. RESULTS: Overall, 5592 pediatric patients were treated with CPR, of whom 2799 (50.1%) received CPR for bradycardia with poor perfusion and 2793 (49.9%) for initial pulseless cardiac arrest. Among those with bradycardia, 869 (31.0%, or 15.5% of cohort) became pulseless after a median of 3 minutes of CPR (interquartile range, 1-9 minutes). Rates of survival to discharge were 70.0% (1351 of 1930) for bradycardia with pulse, 30.1% (262 of 869) for bradycardia progressing to pulselessness, and 37.5% (1046 of 2793) for initial pulseless cardiac arrest (P for difference across groups <0.001). Children who became pulseless despite CPR for bradycardia had a 19% lower likelihood (risk ratio, 0.81 [95% CI, 0.70, 0.93]; P=0.004) of surviving to hospital discharge than those who were initially pulseless. Among children who progressed to pulselessness despite CPR for bradycardia, a longer interval between CPR and pulselessness was a predictor of lower survival (reference, <2 minutes; for 2-5 minutes, risk ratio, 0.54 [95% CI, 0.41-0.70]; for >5 minutes, risk ratio, 0.41 [95% CI, 0.32-0.53]). CONCLUSIONS: Among hospitalized children in whom CPR is initiated, half have bradycardia with poor perfusion at the initiation of chest compressions, and nearly one-third of these progress to pulseless in-hospital cardiac arrest despite CPR. Survival was significantly lower for children who progress to pulselessness despite CPR compared with those who were initially pulseless. These findings suggest that pediatric patients who lose their pulse despite resuscitation attempts are at particularly high risk and require a renewed focus on postresuscitation care.


Assuntos
Bradicardia/mortalidade , Bradicardia/terapia , Reanimação Cardiopulmonar/mortalidade , Criança Hospitalizada , Pulso Arterial/mortalidade , Reanimação Cardiopulmonar/tendências , Criança , Pré-Escolar , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Humanos , Lactente , Masculino , Pulso Arterial/tendências , Taxa de Sobrevida/tendências
19.
JAMA ; 321(12): 1165-1175, 2019 03 26.
Artigo em Inglês | MEDLINE | ID: mdl-30912836

RESUMO

Importance: Preterm infants must establish regular respirations at delivery. Sustained inflations may establish lung volume faster than short inflations. Objective: To determine whether a ventilation strategy including sustained inflations, compared with standard intermittent positive pressure ventilation, reduces bronchopulmonary dysplasia (BPD) or death at 36 weeks' postmenstrual age without harm in extremely preterm infants. Design, Setting, and Participants: Unmasked, randomized clinical trial (August 2014 to September 2017, with follow-up to February 15, 2018) conducted in 18 neonatal intensive care units in 9 countries. Preterm infants 23 to 26 weeks' gestational age requiring resuscitation with inadequate respiratory effort or bradycardia were enrolled. Planned enrollment was 600 infants. The trial was stopped after enrolling 426 infants, following a prespecified review of adverse outcomes. Interventions: The experimental intervention was up to 2 sustained inflations at maximal peak pressure of 25 cm H2O for 15 seconds using a T-piece and mask (n = 215); standard resuscitation was intermittent positive pressure ventilation (n = 211). Main Outcome and Measures: The primary outcome was the rate of BPD or death at 36 weeks' postmenstrual age. There were 27 prespecified secondary efficacy outcomes and 7 safety outcomes, including death at less than 48 hours. Results: Among 460 infants randomized (mean [SD] gestational age, 25.30 [0.97] weeks; 50.2% female), 426 infants (92.6%) completed the trial. In the sustained inflation group, 137 infants (63.7%) died or survived with BPD vs 125 infants (59.2%) in the standard resuscitation group (adjusted risk difference [aRD], 4.7% [95% CI, -3.8% to 13.1%]; P = .29). Death at less than 48 hours of age occurred in 16 infants (7.4%) in the sustained inflation group vs 3 infants (1.4%) in the standard resuscitation group (aRD, 5.6% [95% CI, 2.1% to 9.1%]; P = .002). Blinded adjudication detected an imbalance of rates of early death possibly attributable to resuscitation (sustained inflation: 11/16; standard resuscitation: 1/3). Of 27 secondary efficacy outcomes assessed by 36 weeks' postmenstrual age, 26 showed no significant difference between groups. Conclusions and Relevance: Among extremely preterm infants requiring resuscitation at birth, a ventilation strategy involving 2 sustained inflations, compared with standard intermittent positive pressure ventilation, did not reduce the risk of BPD or death at 36 weeks' postmenstrual age. These findings do not support the use of ventilation with sustained inflations among extremely preterm infants, although early termination of the trial limits definitive conclusions. Trial Registration: clinicaltrials.gov Identifier: NCT02139800.


Assuntos
Asfixia Neonatal/terapia , Lactente Extremamente Prematuro , Ventilação com Pressão Positiva Intermitente , Respiração com Pressão Positiva/métodos , Asfixia Neonatal/fisiopatologia , Bradicardia/terapia , Displasia Broncopulmonar/etiologia , Feminino , Capacidade Residual Funcional , Idade Gestacional , Frequência Cardíaca , Mortalidade Hospitalar , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Respiração com Pressão Positiva/efeitos adversos , Ressuscitação/métodos
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