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1.
Pediatr Rheumatol Online J ; 19(1): 29, 2021 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-33726806

RESUMO

BACKGROUND: There is mounting evidence on the existence of a Pediatric Inflammatory Multisystem Syndrome-temporally associated to SARS-CoV-2 infection (PIMS-TS), sharing similarities with Kawasaki Disease (KD). The main outcome of the study were to better characterize the clinical features and the treatment response of PIMS-TS and to explore its relationship with KD determining whether KD and PIMS are two distinct entities. METHODS: The Rheumatology Study Group of the Italian Pediatric Society launched a survey to enroll patients diagnosed with KD (Kawasaki Disease Group - KDG) or KD-like (Kawacovid Group - KCG) disease between February 1st 2020, and May 31st 2020. Demographic, clinical, laboratory data, treatment information, and patients' outcome were collected in an online anonymized database (RedCAP®). Relationship between clinical presentation and SARS-CoV-2 infection was also taken into account. Moreover, clinical characteristics of KDG during SARS-CoV-2 epidemic (KDG-CoV2) were compared to Kawasaki Disease patients (KDG-Historical) seen in three different Italian tertiary pediatric hospitals (Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste; AOU Meyer, Florence; IRCCS Istituto Giannina Gaslini, Genoa) from January 1st 2000 to December 31st 2019. Chi square test or exact Fisher test and non-parametric Wilcoxon Mann-Whitney test were used to study differences between two groups. RESULTS: One-hundred-forty-nine cases were enrolled, (96 KDG and 53 KCG). KCG children were significantly older and presented more frequently from gastrointestinal and respiratory involvement. Cardiac involvement was more common in KCG, with 60,4% of patients with myocarditis. 37,8% of patients among KCG presented hypotension/non-cardiogenic shock. Coronary artery abnormalities (CAA) were more common in the KDG. The risk of ICU admission were higher in KCG. Lymphopenia, higher CRP levels, elevated ferritin and troponin-T characterized KCG. KDG received more frequently immunoglobulins (IVIG) and acetylsalicylic acid (ASA) (81,3% vs 66%; p = 0.04 and 71,9% vs 43,4%; p = 0.001 respectively) as KCG more often received glucocorticoids (56,6% vs 14,6%; p < 0.0001). SARS-CoV-2 assay more often resulted positive in KCG than in KDG (75,5% vs 20%; p < 0.0001). Short-term follow data showed minor complications. Comparing KDG with a KD-Historical Italian cohort (598 patients), no statistical difference was found in terms of clinical manifestations and laboratory data. CONCLUSION: Our study suggests that SARS-CoV-2 infection might determine two distinct inflammatory diseases in children: KD and PIMS-TS. Older age at onset and clinical peculiarities like the occurrence of myocarditis characterize this multi-inflammatory syndrome. Our patients had an optimal response to treatments and a good outcome, with few complications and no deaths.


Assuntos
/fisiopatologia , Doença da Artéria Coronariana/fisiopatologia , Hipotensão/fisiopatologia , Linfopenia/fisiopatologia , Síndrome de Linfonodos Mucocutâneos/fisiopatologia , Miocardite/fisiopatologia , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologia , Distribuição por Idade , Antirreumáticos/uso terapêutico , Aspirina/uso terapêutico , Proteína C-Reativa/metabolismo , /metabolismo , Criança , Pré-Escolar , Tosse/fisiopatologia , Diarreia/fisiopatologia , Dispneia/fisiopatologia , Feminino , Glucocorticoides/uso terapêutico , Insuficiência Cardíaca/fisiopatologia , Humanos , /fisiopatologia , Imunoglobulinas Intravenosas/uso terapêutico , Fatores Imunológicos/uso terapêutico , Lactente , Unidades de Terapia Intensiva Pediátrica , Proteína Antagonista do Receptor de Interleucina 1/uso terapêutico , Itália/epidemiologia , Masculino , Síndrome de Linfonodos Mucocutâneos/epidemiologia , Síndrome de Linfonodos Mucocutâneos/metabolismo , Síndrome de Linfonodos Mucocutâneos/terapia , Inibidores da Agregação de Plaquetas/uso terapêutico , Choque/fisiopatologia , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia , Síndrome de Resposta Inflamatória Sistêmica/metabolismo , Síndrome de Resposta Inflamatória Sistêmica/terapia , Taquipneia/fisiopatologia , Troponina T/metabolismo , Vômito/fisiopatologia
2.
Anesth Analg ; 132(3): 777-787, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33591093

RESUMO

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24-31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.


Assuntos
Oxigenação por Membrana Extracorpórea , Complicações Cardiovasculares na Gravidez/terapia , Transtornos Puerperais/terapia , Insuficiência Respiratória/terapia , Choque/terapia , Adulto , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Recém-Nascido , Nascimento Vivo , Período Pós-Parto , Gravidez , Complicações Cardiovasculares na Gravidez/mortalidade , Complicações Cardiovasculares na Gravidez/fisiopatologia , Transtornos Puerperais/mortalidade , Transtornos Puerperais/fisiopatologia , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Choque/mortalidade , Choque/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
5.
BMJ Case Rep ; 14(1)2021 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-33462030

RESUMO

This case represents a rare fulminant course of fried-rice associated food poisoning in an immunocompetent person due to pre-formed exotoxin produced by Bacillus cereus, with severe manifestations of sepsis, including multi-organ (hepatic, renal, cardiac, respiratory and neurological) failure, shock, metabolic acidosis, rhabdomyolysis and coagulopathy. Despite maximal supportive measures (continuous renal replacement therapy, plasmapheresis, N-acetylcysteine infusion and blood products, and broad-spectrum antimicrobials) and input from a multidisciplinary team (consisting of infectious diseases, intensive care, gastroenterology, surgery, toxicology, immunology and haematology), mortality resulted. This case is the first to use whole genome sequencing techniques to confirm the toxigenic potential of B. cereus It has important implications for food preparation and storage, particularly given its occurrence in home isolation during the COVID-19 pandemic.


Assuntos
Bacillus cereus/genética , Exotoxinas/genética , Doenças Transmitidas por Alimentos/diagnóstico , Acetilcisteína/uso terapêutico , Acidose/fisiopatologia , Acidose/terapia , Adulto , Antiarrítmicos/uso terapêutico , Antibacterianos/uso terapêutico , Arritmias Cardíacas/fisiopatologia , Arritmias Cardíacas/terapia , Bacillus cereus/isolamento & purificação , Transtornos da Coagulação Sanguínea/fisiopatologia , Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue , Encefalopatias , Terapia de Substituição Renal Contínua , Evolução Fatal , Feminino , Doenças Transmitidas por Alimentos/microbiologia , Doenças Transmitidas por Alimentos/fisiopatologia , Doenças Transmitidas por Alimentos/terapia , Depuradores de Radicais Livres/uso terapêutico , Humanos , Imunocompetência , Falência Hepática/fisiopatologia , Falência Hepática/terapia , Insuficiência de Múltiplos Órgãos/fisiopatologia , Insuficiência de Múltiplos Órgãos/terapia , Plasmaferese , Insuficiência Renal/fisiopatologia , Insuficiência Renal/terapia , Rabdomiólise/fisiopatologia , Rabdomiólise/terapia , Sepse/fisiopatologia , Sepse/terapia , Choque/fisiopatologia , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Sequenciamento Completo do Genoma
6.
Emerg Med Clin North Am ; 38(4): 783-793, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981617

RESUMO

Intravenous (IV) fluids are among the most common interventions performed in the emergency department. They are at times lifesaving, but if used recklessly can be harmful. Given their ubiquity, it is important to understand the history, physiology, and current strategies that govern the use of IV fluids during the resuscitation of the critically ill.


Assuntos
Hidratação , Ressuscitação/métodos , Coloides/uso terapêutico , Circulação Coronária/fisiologia , Soluções Cristaloides/química , Soluções Cristaloides/uso terapêutico , Eletrólitos/análise , Serviço Hospitalar de Emergência , Hidratação/história , História do Século XIX , História do Século XX , Humanos , Choque/fisiopatologia , Pressão Venosa/fisiologia
7.
Anaesth Crit Care Pain Med ; 39(5): 563-569, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32781167

RESUMO

PURPOSE: To survey haemodynamic monitoring and management practices in intensive care patients with the coronavirus disease 2019 (COVID-19). METHODS: A questionnaire was shared on social networks or via email by the authors and by Anaesthesia and/or Critical Care societies from France, Switzerland, Belgium, Brazil, and Portugal. Intensivists and anaesthetists involved in COVID-19 ICU care were invited to answer 14 questions about haemodynamic monitoring and management. RESULTS: Globally, 1000 questionnaires were available for analysis. Responses came mainly from Europe (n = 460) and America (n = 434). According to a majority of respondents, COVID-19 ICU patients frequently or very frequently received continuous vasopressor support (56%) and had an echocardiography performed (54%). Echocardiography revealed a normal cardiac function, a hyperdynamic state (43%), hypovolaemia (22%), a left ventricular dysfunction (21%) and a right ventricular dilation (20%). Fluid responsiveness was frequently assessed (84%), mainly using echo (62%), and cardiac output was measured in 69%, mostly with echo as well (53%). Venous oxygen saturation was frequently measured (79%), mostly from a CVC blood sample (94%). Tissue perfusion was assessed biologically (93%) and clinically (63%). Pulmonary oedema was detected and quantified mainly using echo (67%) and chest X-ray (61%). CONCLUSION: Our survey confirms that vasopressor support is not uncommon in COVID-19 ICU patients and suggests that different haemodynamic phenotypes may be observed. Ultrasounds were used by many respondents, to assess cardiac function but also to predict fluid responsiveness and quantify pulmonary oedema. Although we observed regional differences, current international guidelines were followed by most respondents.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Cuidados Críticos/métodos , Pesquisas sobre Serviços de Saúde , Monitorização Hemodinâmica , Pandemias , Pneumonia Viral/terapia , África/epidemiologia , América/epidemiologia , Ásia/epidemiologia , Austrália/epidemiologia , Cardiotônicos/uso terapêutico , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/fisiopatologia , Gerenciamento Clínico , Ecocardiografia/estatística & dados numéricos , Europa (Continente)/epidemiologia , Hidratação , Hemodinâmica/efeitos dos fármacos , Humanos , Oxigênio/sangue , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Pneumonia Viral/fisiopatologia , Utilização de Procedimentos e Técnicas , Edema Pulmonar/etiologia , Edema Pulmonar/fisiopatologia , Choque/etiologia , Choque/fisiopatologia , Vasoconstritores/uso terapêutico
8.
Artigo em Inglês | MEDLINE | ID: mdl-32646021

RESUMO

Deciding between palliative and overly aggressive therapies for advanced cancer patients who present to the emergency department (ED) with acute issues requires a prediction of their short-term survival. Various scoring systems have previously been studied in hospices or intensive care units, though they are unsuitable for use in the ED. We aim to examine the use of a shock index (SI) in predicting the 60-day survival of advanced cancer patients presenting to the ED. Identified high-risk patients and their families can then be counseled accordingly. Three hundred and five advanced cancer patients who presented to the EDs of three tertiary hospitals were recruited, and their data retrospectively analyzed. Relevant data regarding medical history and clinical presentation were extracted, and respective shock indices calculated. Multivariate logistic regression analyses were performed. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of the SI. Nonsurvivors within 60 days had significantly lower body temperatures and blood pressure, as well as higher pulse rates, respiratory rates, and SI. Each 0.1 SI increment had an odds ratio of 1.39 with respect to 60-day mortality. The area under the ROC curve was 0.7511. At the optimal cut-off point of 0.94, the SI had 81.38% sensitivity and 73.11% accuracy. This makes the SI an ideal evaluation tool for rapidly predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. Identified patients can be counseled accordingly, and they can be assisted in making informed decisions on the appropriate treatment goals reflective of their prognoses.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Mortalidade Hospitalar , Neoplasias Nasofaríngeas/mortalidade , Neoplasias Nasofaríngeas/patologia , Choque/mortalidade , Humanos , Masculino , Curva ROC , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque/fisiopatologia , Fatores de Tempo
9.
Ann Neurol ; 88(4): 851-854, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32613682

RESUMO

Many patients with severe coronavirus disease 2019 (COVID-19) remain unresponsive after surviving critical illness. Although several structural brain abnormalities have been described, their impact on brain function and implications for prognosis are unknown. Functional neuroimaging, which has prognostic significance, has yet to be explored in this population. Here we describe a patient with severe COVID-19 who, despite prolonged unresponsiveness and structural brain abnormalities, demonstrated intact functional network connectivity, and weeks later recovered the ability to follow commands. When prognosticating for survivors of severe COVID-19, clinicians should consider that brain networks may remain functionally intact despite structural injury and prolonged unresponsiveness. ANN NEUROL 2020;88:851-854.


Assuntos
Encéfalo/diagnóstico por imagem , Coma/diagnóstico por imagem , Infecções por Coronavirus/fisiopatologia , Estado Vegetativo Persistente/diagnóstico por imagem , Pneumonia Viral/fisiopatologia , Recuperação de Função Fisiológica , Betacoronavirus , Encéfalo/fisiopatologia , Coma/fisiopatologia , Infecções por Coronavirus/terapia , Eletroencefalografia , Neuroimagem Funcional , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Vias Neurais , Pandemias , Estado Vegetativo Persistente/fisiopatologia , Pneumonia Viral/terapia , Prognóstico , Insuficiência Renal/fisiopatologia , Respiração Artificial , /terapia , Choque/fisiopatologia
10.
Neurology ; 95(10): 454-457, 2020 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-32586898

Assuntos
Infarto Cerebral/diagnóstico por imagem , Infecções por Coronavirus/diagnóstico por imagem , Globo Pálido/diagnóstico por imagem , Hipóxia/diagnóstico , Pneumonia Viral/diagnóstico por imagem , Betacoronavirus , Infarto Cerebral/complicações , Infarto Cerebral/metabolismo , Infarto Cerebral/fisiopatologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/metabolismo , Infecções por Coronavirus/fisiopatologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/metabolismo , Cetoacidose Diabética/complicações , Cetoacidose Diabética/metabolismo , Diagnóstico Diferencial , Feminino , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/complicações , Coma Hiperglicêmico Hiperosmolar não Cetótico/metabolismo , Hipertensão/complicações , Hipertensão/fisiopatologia , Hipóxia/complicações , Hipóxia/metabolismo , Hipóxia-Isquemia Encefálica/diagnóstico , Leucoencefalite Hemorrágica Aguda/diagnóstico , Pulmão/diagnóstico por imagem , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/metabolismo , Pneumonia Viral/fisiopatologia , Insuficiência Respiratória/complicações , Insuficiência Respiratória/metabolismo , Insuficiência Respiratória/fisiopatologia , Choque/complicações , Choque/metabolismo , Choque/fisiopatologia , Veia Subclávia/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Trombose Venosa/complicações , Trombose Venosa/diagnóstico por imagem
11.
Am J Respir Crit Care Med ; 202(1): 91-99, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32272020

RESUMO

Rationale: Guidelines for vasopressor titration suggest a universal target-mean arterial pressure (MAP) >65 mm Hg. The implications for patients with premorbid low/high blood pressure are unknown.Objectives: To investigate the relationship between premorbid blood pressure and vasopressor duration for patients with shock.Methods: We performed a retrospective cohort study of adults admitted with shock to Calgary ICUs (June 2012-December 2018). The primary exposure was premorbid blood pressure: low (systolic <100); normal (systolic 100-139 and diastolic <90); and high (systolic ≥140 or diastolic ≥90). The primary outcome was vasopressor duration; secondary outcomes included ICU/hospital length of stay and ICU/hospital mortality. We examined associations of premorbid blood pressure with vasopressor duration and length of stay using multivariable competing risk models and mortality using multivariable mixed-effects logistic regression.Measurements and Main Results: Of 3,542 admissions with shock, 177 (5.0%) had premorbid low, 2,887 (81.5%) normal, and 478 (13.5%) high blood pressure. Premorbid low admissions had lower MAPs (vs. normal or high premorbid admissions) over the duration of vasopressor use (P = 0.003) and were maintained nearest premorbid MAPs while receiving vasopressors (P < 0.001). After adjustment, premorbid low admissions had longer vasopressor use (median, 1.35 d vs. 1.04 d for normal; hazard ratio for discontinuation vs. normal, 0.78 [0.73-0.85]; P < 0.001) and premorbid high admissions had shorter use (median, 0.84 d; hazard ratio, 1.22 [1.12-1.33]; P < 0.001). Premorbid low admissions had longer adjusted length of stay and higher adjusted mortality than premorbid normal admissions.Conclusions: Premorbid blood pressure was inversely associated with vasopressor duration.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Hipertensão/complicações , Hipotensão/complicações , Padrões de Prática Médica/estatística & dados numéricos , Choque/tratamento farmacológico , Vasoconstritores/administração & dosagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alberta , Feminino , Humanos , Hipertensão/fisiopatologia , Hipotensão/fisiopatologia , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Choque/complicações , Choque/mortalidade , Choque/fisiopatologia , Resultado do Tratamento , Vasoconstritores/farmacologia , Vasoconstritores/uso terapêutico , Adulto Jovem
14.
PLoS One ; 15(2): e0228274, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32053637

RESUMO

OBJECTIVE: Fluid overload is common among critically ill patients and is associated with worse outcomes. We aimed to assess the effect of diuretics on urine output, vasopressor dose, acute kidney injury (AKI) incidence, and need for renal replacement therapies (RRT) among patients who receive vasopressors. PATIENTS AND METHODS: This is a single-center retrospective study of all adult patients admitted to the intensive care unit between January 2006 and December 2016 and received >6 hours of vasopressor therapy and at least one concomitant dose of diuretic. We excluded patients from cardiac care units. Hourly urine output and vasopressor dose for 6 hours before and after the first dose of diuretic therapy was compared. Rates of AKI development and RRT initiation were assessed with a propensity-matched cohort of patients who received vasopressors but did not receive diuretics. RESULTS: There was an increasing trend of prescribing diuretics in patients receiving vasopressors over the course of the study. We included 939 patients with median (IQR) age of 68(57, 78) years old and 400 (43%) female. The average hourly urine output during the first six hours following time zero in comparison with average hourly urine output during the six hours prior to time zero was significantly higher in diuretic group in comparison with patients who did not receive diuretics [81 (95% CI 73-89) ml/h vs. 42 (95% CI 39-45) ml/h, respectively; p<0.001]. After propensity matching, the rate of AKI within 7 days of exposure and the need for RRT were similar between the study and matched control patients (66 (15.6%) vs. 83 (19.6%), p = 0.11, and 34 (8.0%) vs. 37 (8.7%), p = 0.69, respectively). Mortality, however, was higher in the group that received diuretics. Ninety-day mortality was 191 (45.2%) in the exposed group VS 156 (36.9%) p = .009. CONCLUSIONS: While the use of diuretic therapy in critically ill patients receiving vasopressor infusions augmented urine output, it was not associated with higher vasopressor requirements, AKI incidence, and need for renal replacement therapy.


Assuntos
Diuréticos/farmacologia , Choque/tratamento farmacológico , Vasoconstritores/farmacologia , Lesão Renal Aguda/complicações , Idoso , Estudos de Coortes , Estado Terminal , Interações Medicamentosas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia de Substituição Renal , Estudos Retrospectivos , Choque/complicações , Choque/fisiopatologia , Choque/urina , Resultado do Tratamento , Vasoconstritores/uso terapêutico
15.
Crit Care ; 24(1): 43, 2020 02 06.
Artigo em Inglês | MEDLINE | ID: mdl-32028998

RESUMO

BACKGROUND: In patients with vasodilatory shock, plasma concentrations of angiotensin I (ANG I) and II (ANG II) and their ratio may reflect differences in the response to severe vasodilation, provide novel insights into its biology, and predict clinical outcomes. The objective of these protocol prespecified and subsequent post hoc analyses was to assess the epidemiology and outcome associations of plasma ANG I and ANG II levels and their ratio in patients with catecholamine-resistant vasodilatory shock (CRVS) enrolled in the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) study. METHODS: We measured ANG I and ANG II levels at baseline, calculated their ratio, and compared these results to values from healthy volunteers (controls). We dichotomized patients according to the median ANG I/II ratio (1.63) and compared demographics, clinical characteristics, and clinical outcomes. We constructed a Cox proportional hazards model to test the independent association of ANG I, ANG II, and their ratio with clinical outcomes. RESULTS: Median baseline ANG I level (253 pg/mL [interquartile range (IQR) 72.30-676.00 pg/mL] vs 42 pg/mL [IQR 30.46-87.34 pg/mL] in controls; P <  0.0001) and median ANG I/II ratio (1.63 [IQR 0.98-5.25] vs 0.4 [IQR 0.28-0.64] in controls; P <  0.0001) were elevated, whereas median ANG II levels were similar (84 pg/mL [IQR 23.85-299.50 pg/mL] vs 97 pg/mL [IQR 35.27-181.01 pg/mL] in controls; P = 0.9895). At baseline, patients with a ratio above the median (≥1.63) had higher ANG I levels (P <  0.0001), lower ANG II levels (P <  0.0001), higher albumin concentrations (P = 0.007), and greater incidence of recent (within 1 week) exposure to angiotensin-converting enzyme inhibitors (P <  0.00001), and they received a higher norepinephrine-equivalent dose (P = 0.003). In the placebo group, a baseline ANG I/II ratio <1.63 was associated with improved survival (hazard ratio 0.56; 95% confidence interval 0.36-0.88; P = 0.01) on unadjusted analyses. CONCLUSIONS: Patients with CRVS have elevated ANG I levels and ANG I/II ratios compared with healthy controls. In such patients, a high ANG I/II ratio is associated with greater norepinephrine requirements and is an independent predictor of mortality, thus providing a biological rationale for interventions aimed at its correction. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02338843. Registered 14 January 2015.


Assuntos
Angiotensina II/análise , Angiotensina I/análise , Choque/sangue , Angiotensina I/sangue , Angiotensina II/sangue , Catecolaminas/uso terapêutico , Feminino , Humanos , Masculino , Choque/fisiopatologia
16.
Arch Cardiol Mex ; 90(1): 47-54, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31996854

RESUMO

One-third of the population in intensive care units is in a state of circulatory shock, whose rapid recognition and mechanism differentiation are of great importance. The clinical context and physical examination are of great value, but in complex situations as in cardiac care units, it is mandatory the use of advanced hemodynamic monitorization devices, both to determine the main mechanism of shock, as to decide management and guide response to treatment, these devices include pulmonary flotation catheter as the gold standard, as well as more recent techniques including echocardiography and pulmonary ultrasound, among others. This article emphasizes the different shock mechanisms observed in the cardiac care units, with a proposal for approach and treatment.


Assuntos
Unidades de Cuidados Coronarianos , Hemodinâmica/fisiologia , Choque/fisiopatologia , Ecocardiografia/métodos , Humanos , Choque/terapia , Choque Cardiogênico/fisiopatologia , Choque Cardiogênico/terapia , Ultrassonografia/métodos
17.
Crit Care ; 24(1): 25, 2020 01 28.
Artigo em Inglês | MEDLINE | ID: mdl-31992351

RESUMO

RATIONALE: There remains significant controversy regarding the optimal approach to fluid resuscitation for patients in shock. The magnitude of care variability in shock resuscitation, the confounding effects of disease severity and comorbidity, and the relative impact on sepsis survival are poorly understood. OBJECTIVE: To evaluate usual care variability and determine the differential effect of observed and predicted fluid resuscitation volumes on risk-adjusted hospital mortality for mechanically ventilated patients in shock. METHODS: We performed a retrospective outcome analysis of mechanically ventilated patients admitted to intensive care units using the 2013 Premier Hospital Database (Premier, Inc.). Observed and predicted hospital mortality were evaluated by observed and predicted day 1 fluid administration, using the difference in predicted and observed outcomes to adjust for disease severity between groups. Both predictive models were validated using a second large administrative database (Truven Health Analytics Inc.). Secondary outcomes included duration of mechanical ventilation, hospital and ICU length of stay, and cost. RESULTS: Among 33,831 patients, observed hospital mortality was incrementally higher than predicted for each additional liter of day 1 fluid beginning at 7 L (40.9% vs. 37.2%, p = 0.008). Compared to patients that received expected (± 1.5 L predicted) day 1 fluid volumes, greater-than-expected fluid resuscitation was associated with increased risk-adjusted hospital mortality (52.3% vs. 45.0%, p < 0.0001) among all patients with shock and among a subgroup of shock patients with comorbid conditions predictive of lower fluid volume administration (47.1% vs. 41.5%, p < 0.0001). However, in patients with shock but without such conditions, both greater-than-expected (57.5% vs. 49.2%, p < 0.0001) and less-than-expected (52.1% vs. 49.2%, p = 0.037) day 1 fluid resuscitation were associated with increased risk-adjusted hospital mortality. CONCLUSIONS: Highly variable day 1 fluid resuscitation was associated with a non-uniform impact on risk-adjusted hospital mortality among distinct subgroups of mechanically ventilated patients with shock. These findings support closer evaluation of fluid resuscitation strategies that include broadly applied fluid volume targets in the early phase of shock resuscitation.


Assuntos
Hidratação/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Choque/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Área Sob a Curva , Feminino , Hidratação/instrumentação , Hidratação/normas , Humanos , Masculino , Pessoa de Meia-Idade , Curva ROC , Respiração Artificial/métodos , Ressuscitação/instrumentação , Ressuscitação/métodos , Ressuscitação/normas , Estudos Retrospectivos , Risco Ajustado/métodos , Choque/fisiopatologia
18.
Blood Purif ; 49(1-2): 143-150, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31851980

RESUMO

This paper briefly reviews the physiological components of the microcirculation, focusing on its function in homeostasis and its central function in the realization of oxygen transport to tissue cells. Its pivotal role in the understanding of circulatory compromise in states of shock and renal compromise is discussed. Our introduction of hand-held vital microscopes (HVM) to clinical medicine has revealed the importance of the microcirculation as a central target organ in states of critical illness and inadequate response to therapy. Technical and methodological developments have been made in hardware and in software including our recent introduction and validation of automatic analysis software called MicroTools, which now allows point-of-care use of HVM imaging at the bedside for instant availability of functional microcirculatory parameters needed for microcirculatory targeted resuscitation procedures to be a reality.


Assuntos
Processamento de Imagem Assistida por Computador , Microscopia Intravital , Nefropatias , Microcirculação , Sistemas Automatizados de Assistência Junto ao Leito , Choque , Software , Humanos , Nefropatias/diagnóstico por imagem , Nefropatias/fisiopatologia , Choque/diagnóstico por imagem , Choque/fisiopatologia
19.
Emerg Med J ; 37(3): 155-161, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31757833

RESUMO

Worldwide there is a shortage of available organs for patients requiring transplants. However, some countries such as France, Italy and Spain have had greater success by allowing donations from patients with unexpected and unrecoverable circulatory arrest who arrive in the ED. Significant advances in the surgical approach to organ recovery from donation after circulatory death (DCD) led to the establishment of a pilot programme for uncontrolled DCD in the ED of the Royal Infirmary of Edinburgh. This paper describes the programme and discusses the lessons learnt.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Choque/fisiopatologia , Obtenção de Tecidos e Órgãos/normas , Serviço Hospitalar de Emergência/organização & administração , Humanos , Projetos Piloto , Doadores de Tecidos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Reino Unido
20.
J Ultrasound Med ; 39(2): 231-238, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31283047

RESUMO

OBJECTIVES: Although inferior vena cava diameter (IVCD) measurement can be useful as a noninvasive method for monitoring the volume status, the benefit of abdominal aorta diameter (AAD) measurement is unclear. The purpose of this study was to determine the value of the combined use of the IVCD and AAD in blood loss monitoring. METHODS: This prospective observational study was conducted at the blood donor center of a training and research hospital. Standard blood donation criteria were followed during volunteer enrollment. Vital signs and ultrasound IVCD and AAD measurements were obtained before and after blood donation and after fluid resuscitation with 500 mL of 0.9% sodium chloride. Measurements before and after blood donation and after fluid resuscitation were compared by the paired t and Wilcoxon matched-pair tests. RESULTS: Thirty-nine volunteers were included in the study. With 500 mL of blood loss, percent changes in the shock index (SI; mean ± SD, 7% ± 6%), IVCD (6% ± 2%), and caval/aorta index (IVCD/AAD; 6.1% ± 3%) were similar and were higher (P < .001 for all parameters) than the changes in the pulse rate (3% ± 4%), AAD (0.5% ± 1.5%), systolic blood pressure (3% ± 4%), and diastolic blood pressure (2% ± 7%). Although IVCD and SI values changed significantly (P < .001 for both) after 500 mL of 0.9% sodium chloride resuscitation, no significant change was observed in the IVCD/AAD (P = .059). CONCLUSIONS: The IVCD/AAD, SI, and IVCD may have similar success rates in diagnosing early blood loss. Additionally, the SI and IVCD may be superior to the IVCD/AAD in bleeding patients requiring simultaneous fluid resuscitation.


Assuntos
Aorta Abdominal/diagnóstico por imagem , Voluntários Saudáveis , Veia Cava Inferior/diagnóstico por imagem , Adolescente , Adulto , Doadores de Sangue , Volume Sanguíneo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ressuscitação , Choque/diagnóstico por imagem , Choque/fisiopatologia
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