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1.
J Stroke Cerebrovasc Dis ; 30(1): 105413, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33160127

RESUMO

BACKGROUND: In adult patients with moyamoya disease (MMD) underwent combined revascularization, cerebral infarction during the acute postoperative phase is common and can lead to neurological dysfunction after revascularization in MMD patients. The aim of this study was to share the experience of individualized perioperative blood pressure (BP) management for adult MMD patients in one single center. METHODS: We retrospectively reviewed 144 adult patients with MMD who underwent 186 procedures of combined revascularization at our institution from March 2013 to July 2019. Clinical features and outcomes were analyzed, in particular regarding cerebral infarction and hyperperfusion syndrome (HPS). All of the patients received individualized management perioperatively, especially about the blood pressure management according to the characteristics of moyamoya disease. RESULTS: Postoperative cerebral infarction and HPS within 14 days after revascularization were recorded. Cerebral infarction occurred in four (2.1%) procedures among four patients. No patients suffered from a malignant cerebral infarction and only one patient had permanent neurological deficits. The incidence of HPS was 10.8% and no one presented with intracranial hemorrhage. All of the symptoms were reversible without any brain parenchymal injury. CONCLUSIONS: Our findings suggest that we can decrease the incidence and extent of cerebral infarction in adult MMD patients following combined revascularization by individualized perioperative BP management.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Infarto Cerebral/prevenção & controle , Revascularização Cerebral , Hidratação , Doença de Moyamoya/cirurgia , Assistência Perioperatória , Adulto , Anti-Hipertensivos/efeitos adversos , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/etiologia , Infarto Cerebral/fisiopatologia , Revascularização Cerebral/efeitos adversos , Circulação Cerebrovascular , Feminino , Hidratação/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Moyamoya/diagnóstico por imagem , Doença de Moyamoya/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
2.
Mayo Clin Proc ; 95(8): 1660-1670, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32605782

RESUMO

OBJECTIVE: To compare elastic bandage (EB) vs hypertonic albumin solution administration to increase fluid removal by enhancing loop diuretic efficiency (DE) in patients with volume overload and diuretic resistance. PATIENTS AND METHODS: In this historic cohort study with propensity matching, we included diuretic-resistant adult (≥18 years) patients with volume overload after fluid resuscitation admitted in the intensive care unit from January 1, 2006, through June 30, 2017. Regression models and propensity matching were used to assess the associations of these interventions with changes in DE and other clinical outcomes. RESULTS: Of 1147 patients (median age, 66; interquartile range [IQR], 56-76 years; 51% [n=590] men), 384 (33%) received EB and 763 (67%) received hypertonic albumin solution. In adjusted models, EB was significantly associated with higher DE compared with hypertonic albumin solution (odds ratio, 1.37; 95% CI, 1.04 to 1.81; P=.004). After propensity matching of 345 pairs, DE remained significantly different between the 2 groups (median, 2111; IQR, 1092 to 4665 mL for EB vs median, 1829; IQR, 1032 to 3436 mL for hypertonic albumin solution; P=.02). EB, male sex, lower baseline serum urea nitrogen level, lower Charlson Comorbidity Index score, and higher baseline left ventricular ejection fraction were DE determinants. The lowest DE quartile (<1073 mL/40-mg furosemide equivalent) following adjustment for known predictors of mortality remained independently associated with higher 90-day death rate (odds ratio, 1.64; 95% CI, 1.13 to 2.36; P=.009). CONCLUSION: EB use is associated with greater DE than hypertonic albumin solution during the deescalation phase of sepsis resuscitation. Prospective clinical trials would validate the findings of this hypothesis-generating study.


Assuntos
Albuminas/uso terapêutico , Bandagens Compressivas/estatística & dados numéricos , Diuréticos/uso terapêutico , Unidades de Terapia Intensiva/estatística & dados numéricos , Solução Salina Hipertônica/uso terapêutico , Desequilíbrio Hidroeletrolítico/terapia , Idoso , Feminino , Hidratação/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Resultado do Tratamento
3.
Medicine (Baltimore) ; 99(29): e21202, 2020 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-32702885

RESUMO

RATIONALE: Capillary leak syndrome is a condition that increases systemic capillary permeability and causes characteristic manifestations such as recurrent hypovolemia, systemic edema, and hemoconcentration. Acute limb compartment syndrome is a possible complication of severe capillary leak syndrome. However, timely diagnosis and prompt treatment are challenging because of atypical presentation. PATIENT CONCERNS: An 18-year-old woman with a history of clinical depression was admitted to our intensive care unit (ICU) because of metformin and vildagliptin overdose. She developed marked vasodilatory shock with recurrent severe hypovolemia and disseminated intravascular coagulation. After urgent hemodialysis and plasma exchange, she started to stabilize hemodynamically. However, her limbs became stone-hard with massive edema. Her serum creatinine kinase level increased to an extremely high level. DIAGNOSIS: Extremities were distended, and her skin developed pallor with blistering. Intramuscular pressure in both forearms and lower legs was significantly elevated. INTERVENTIONS: Decompressive fasciotomy was performed. Hemodialysis was continued because of rhabdomyolyses-induced acute kidney injury. OUTCOMES: The patient was finally able to walk by herself at the time of hospital discharge on day 109. LESSONS: The possibility of acute compartment syndrome should be considered in patients with marked capillary leakage, especially after aggressive fluid resuscitation. It is important to be aware of the compartment syndrome in an ICU setting because communication barriers often mask typical symptoms and make diagnosis difficult.


Assuntos
Síndrome de Vazamento Capilar/etiologia , Síndromes Compartimentais/etiologia , Inibidores da Dipeptidil Peptidase IV/toxicidade , Metformina/efeitos adversos , Adolescente , Síndrome de Vazamento Capilar/complicações , Síndrome de Vazamento Capilar/fisiopatologia , Síndromes Compartimentais/fisiopatologia , Síndromes Compartimentais/cirurgia , Descompressão Cirúrgica/métodos , Inibidores da Dipeptidil Peptidase IV/efeitos adversos , Inibidores da Dipeptidil Peptidase IV/uso terapêutico , Feminino , Hidratação/efeitos adversos , Humanos , Hipoglicemiantes/efeitos adversos , Hipoglicemiantes/uso terapêutico , Unidades de Terapia Intensiva/organização & administração , Metformina/uso terapêutico , Rabdomiólise/complicações , Vildagliptina/efeitos adversos , Vildagliptina/uso terapêutico , Vildagliptina/toxicidade
4.
J Stroke Cerebrovasc Dis ; 29(7): 104916, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32414580

RESUMO

BACKGROUND/OBJECTIVE: Malignant edema can be a life-threatening complication of large hemispheric infarction (LHI), and is often treated with osmotherapy. In this exploratory analysis of data from the GAMES-RP study, we hypothesized that patients receiving osmotherapy had symptomatic cerebral edema, and that treatment with intravenous (IV) glibenclamide would modify osmotherapy use as compared with placebo. METHODS: GAMES-RP was a phase 2 multi-center prospective, double blind, randomized, placebo-controlled study in LHI. Patients were randomized to IV glibenclamide (e.g. IV glyburide) or placebo. Cerebral edema therapies included osmotherapy and/or decompressive craniectomy at the discretion of the treating team. Total bolus osmotherapy dosing was quantified by "osmolar load". Radiographic edema was defined by dichotomizing midline shift at 24 h. Clinical changes were defined as any increase in NIHSS1a. RESULTS: Osmotherapy was administered to 40 of the 77 patients at a median of 39 [27-55] h after stroke onset. The median baseline DWI lesion volume was significantly larger in the osmotherapy treated group (167 [146-211] mL v. 139 [112-170] mL; P=0.046). Adjudicated malignant edema (75% v. 16%; P<0.001) was more common in the osmotherapy treated group. There were no differences in the proportion of patients receiving osmotherapy or the median total osmolar load between treatment arms. Most patients (76%) had a decrease in consciousness (NIHSS item 1A ≥1) on the day they began receiving osmotherapy. CONCLUSIONS: In the GAMES-RP trial, osmolar therapies were most often administered in response to clinical symptoms of decreased consciousness. However, the optimal timing of administration and impact on outcome after LHI have yet to be defined.


Assuntos
Edema Encefálico/terapia , Hidratação , Glibureto/administração & dosagem , Manitol/administração & dosagem , Solução Salina Hipertônica/administração & dosagem , Acidente Vascular Cerebral/terapia , Administração Intravenosa , Idoso , Edema Encefálico/diagnóstico por imagem , Edema Encefálico/fisiopatologia , Craniectomia Descompressiva , Método Duplo-Cego , Feminino , Hidratação/efeitos adversos , Glibureto/efeitos adversos , Humanos , Masculino , Manitol/efeitos adversos , Pessoa de Meia-Idade , Concentração Osmolar , Estudos Prospectivos , Solução Salina Hipertônica/efeitos adversos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
5.
Medicina (B Aires) ; 80(2): 150-156, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32282321

RESUMO

In the last few years the general results in the treatment of acute kidney injury has improved constantly, without a complete comprehension of its pathophysiology. With this paradigm in mind, in these last few years we have seen an evolving comprehension of the possible answers that may be based on recognizing the more proactive role of fluid management in the resuscitation of critical patients, not limited only to the delivery of fluids, but also to their active removal, having as the principal objective the improvement of tissue perfusion. The key role of vascular integrity in fluid overload is discussed, emphasizing the role of the endothelial glycocalyx. Active desresuscitation maneuvers with diuretics or with renal support therapies could be increasingly recognized instruments in the management of fluid overload, particularly in those patients with acute kidney injury.


Assuntos
Lesão Renal Aguda/etiologia , Hidratação , Ressuscitação , Lesão Renal Aguda/fisiopatologia , Lesão Renal Aguda/terapia , Hidratação/efeitos adversos , Hemodinâmica , Humanos
6.
Crit Care ; 24(1): 70, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32111247

RESUMO

OBJECTIVE: Administration of diuretics has been shown to assist fluid management and improve clinical outcomes in the critically ill post-shock resolution. Current guidelines have not yet included standardization or guidance for diuretic-based de-resuscitation in critically ill patients. This study aimed to evaluate the impact of a multi-disciplinary protocol for diuresis-guided de-resuscitation in the critically ill. METHODS: This was a pre-post single-center pilot study within the medical intensive care unit (ICU) of a large academic medical center. Adult patients admitted to the Medical ICU receiving mechanical ventilation with either (1) clinical signs of volume overload via chest radiography or physical exam or (2) any cumulative fluid balance ≥ 0 mL since hospital admission were eligible for inclusion. Patients received diuresis per clinician discretion for a 2-year period (historical control) followed by a diuresis protocol for 1 year (intervention). Patients within the intervention group were matched in a 1:3 ratio with those from the historical cohort who met the study inclusion and exclusion criteria. RESULTS: A total of 364 patients were included, 91 in the protocol group and 273 receiving standard care. Protocolized diuresis was associated with a significant decrease in 72-h post-shock cumulative fluid balance [median, IQR - 2257 (- 5676-920) mL vs 265 (- 2283-3025) mL; p < 0.0001]. In-hospital mortality in the intervention group was lower compared to the historical group (5.5% vs 16.1%; p = 0.008) and higher ICU-free days (p = 0.03). However, no statistically significant difference was found in ventilator-free days, and increased rates of hypernatremia and hypokalemia were demonstrated. CONCLUSIONS: This study showed that a protocol for diuresis for de-resuscitation can significantly improve 72-h post-shock fluid balance with potential benefit on clinical outcomes.


Assuntos
Diurese/efeitos dos fármacos , Diuréticos/administração & dosagem , Hidratação/efeitos adversos , Ressuscitação/efeitos adversos , Idoso , Distribuição de Qui-Quadrado , Protocolos Clínicos , Estado Terminal/terapia , Diuréticos/uso terapêutico , Feminino , Hidratação/métodos , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Desequilíbrio Hidroeletrolítico/tratamento farmacológico , Desequilíbrio Hidroeletrolítico/fisiopatologia
7.
Transplant Proc ; 52(7): 2059-2061, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32217017

RESUMO

BACKGROUND: Anesthesia in patients undergoing kidney transplantation (KTx) should be aimed at creating optimal hemodynamic conditions for the newly implanted kidney. Changes in of blood count, caused mainly by intraoperative hemodilution, may adversely affect the perioperative course by strengthening the pathologic mechanisms of ischemia-reperfusion syndrome. METHODS: A total of 86 patients (mean age: 49.4 ± 14.0 years, 66% men) with end-stage renal disease who underwent KTx between 2012 and 2015 were included in this retrospective study. Our aim was to assess the hemoglobin level and the effect of fluctuations caused by the implemented fluid therapy on graft function and the occurrence of delayed graft failure. RESULTS: There was no difference in baseline characteristics, indication for transplantation, and surgical technique used among study population. Among the whole observation group, no correlation was found between fluid therapy causing hemodilution with a decrease in hemoglobin concentration and the occurrence of delayed graft failure. CONCLUSIONS: In our observations, we paid special attention to the problem of hemodilution in patients undergoing KTx. It is important to emphasize the importance of proper preparation of the patient for KTx by earlier implementation of anemia therapy, thus preventing exacerbation of anemia in the postoperative period, especially because the perioperative use of blood products is associated with numerous complications and a worse prognosis for the newly implanted kidney.


Assuntos
Função Retardada do Enxerto/etiologia , Hidratação/efeitos adversos , Hemodiluição/efeitos adversos , Hemoglobinas/análise , Transplante de Rim/métodos , Adulto , Função Retardada do Enxerto/sangue , Função Retardada do Enxerto/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
8.
Dig Dis Sci ; 65(9): 2700-2711, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-31912265

RESUMO

BACKGROUND/AIMS: Hematocrit is a widely used biomarker to guide early fluid therapy for patients with acute pancreatitis (AP), but there is controversy over whether early rapid fluid therapy (ERFT) should be used in hemoconcentrated patients. This study investigated the association of hematocrit and ERFT with clinical outcomes of patients with AP. METHODS: Data from prospectively maintained AP database and retrospectively collected fluid management details were stratified according to actual severity defined by revised Atlanta classification. Hemoconcentration and "early" were defined as hematocrit > 44% and the first 6 h of general ward admission, respectively, and "rapid" fluid rate was defined as ≥ 3 ml/kg/h. Patients were allocated into 4 groups for comparisons: group A, hematocrit ≤ 44% and fluid rate < 3 ml/kg/h; group B, hematocrit ≤ 44% and fluid rate ≥ 3 ml/kg/h; group C, hematocrit > 44% and fluid rate < 3 ml/kg/h; and group D, hematocrit > 44% and fluid rate ≥ 3 ml/kg/h. Primary outcome was rate of noninvasive positive-pressure ventilation (NPPV). RESULTS: A total of 912 consecutive AP patients were analyzed. ERFT has no impact on clinical outcomes of hemoconcentrated, non-severe or all non-hemoconcentrated AP patients. In hemoconcentrated patients with severe AP (SAP), ERFT was accompanied with increased risk of NPPV (odds ratio 5.96, 95% CI 1.57-22.6). Multivariate regression analyses confirmed ERFT and hemoconcentration were significantly and independently associated with persistent organ failure and mortality in patients with SAP. CONCLUSIONS: ERFT is associated with increased rate of NPPV in hemoconcentrated patients with SAP.


Assuntos
Hidratação , Hematócrito , Ventilação não Invasiva , Pancreatite/terapia , Respiração com Pressão Positiva , Transtornos Respiratórios/terapia , Doença Aguda , Adulto , Idoso , China , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Hidratação/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/efeitos adversos , Pancreatite/sangue , Pancreatite/diagnóstico , Respiração com Pressão Positiva/efeitos adversos , Valor Preditivo dos Testes , Transtornos Respiratórios/diagnóstico , Transtornos Respiratórios/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
9.
Anesth Analg ; 130(1): 151-158, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31846441

RESUMO

BACKGROUND: The end-expiratory occlusion test predicts fluid responsiveness in ventilated intensive care patients; however, its utility in the operating room is questioned. We assessed end-expiratory occlusion test in laparotomic surgery for predicting volume expansion. METHODS: Forty-six patients were included in this study: stage 1 (n = 26) with an end-expiratory occlusion test of 15 seconds, followed by volume expansion, which consisted of 250 mL of colloid over 5 minutes and stage 2 (n = 20) with an end-expiratory occlusion test of 25 seconds followed by volume expansion. The last 10 patients had transdiaphragmatic pressures probed. Patients with an increase in cardiac index >15% after volume expansion were responders. Pulse pressure variation, stroke volume (SV) index, and cardiac index were analyzed. Receiver operating characteristic curves were established for changes in SV and pulse pressure induced by end-expiratory occlusion test and pulse pressure variation using the responders status for volume expansion as outcome. RESULTS: A total of 44 (38%) volume expansions were deemed responders. After end-expiratory occlusion test of 15 seconds, no hemodynamic variables were significantly increased. After end-expiratory occlusion test of 25 seconds, SV index increased in responders (37.1 ± 8.8 mL/m after end-expiratory occlusion test of 25 seconds versus 35.7 ± 8.6 before; P < .0001). End-expiratory occlusion test could not discriminate responders from nonresponders. Only pulse pressure variation had significantly different area under the curve from that expected by chance (0.7 [0.57-0.81]; P = .002 for end-expiratory occlusion test of 15 seconds; and 0.78 [0.64-0.89]; P = .0001 for end-expiratory occlusion test of 25 seconds). After laparotomy, gastric pressure decreased significantly (4 [2.75-5] vs 2 [2-4] cm H2O; P = .0417); no difference was noticed in the transdiaphragmatic gradient. CONCLUSIONS: End-expiratory occlusion test was not reliable to discriminate responders from nonresponders after volume expansion during laparotomic surgery.


Assuntos
Soluções Cristaloides/administração & dosagem , Hidratação , Hemodinâmica , Laparotomia , Monitorização Intraoperatória/métodos , Respiração Artificial , Adulto , Idoso , Soluções Cristaloides/efeitos adversos , Feminino , Hidratação/efeitos adversos , Humanos , Infusões Parenterais , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Tempo
10.
Anesth Analg ; 130(6): 1618-1627, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31856004

RESUMO

BACKGROUND: Several studies of critically ill patients reported that fluid resuscitation with hydroxyethyl starch (HES) solutions damages the kidneys, but their use for surgical patients is debated. Because different HES preparations have different safety profiles, we sought to determine whether 6% third-generation HES 130/0.4 was associated with renal morbidity when used for surgical patients. METHODS: We identified adults enrolled in a Japanese nationwide medical database who underwent surgery between 2014 and 2016, with HES 130/0.4 or without it (controls). These groups were balanced with propensity score matching in a 1:1 ratio without replacement by multivariable logistic regression with 36 covariates, including demographic characteristics, preoperative comorbidities, and anesthetic/surgical procedures. The primary outcome was the incidence of acute kidney injury (AKI) in patients receiving intraoperative HES and controls. Secondary outcomes were assessing whether HES was associated with worsening AKI stage, the incidence of renal-replacement therapy (RRT), hospital length-of-stay, and in-hospital 30-day mortality. Tertiary outcomes include the use of vasoactive agents and the fluid requirement on the day of surgery. Comparative analysis was made with χ, Mann-Whitney U test, or the ordinal logistic regression analysis. RESULTS: Of 76,048 patients in the database, 58,425 were eligible: 9542 received HES and 48,883 controls. Propensity score matching identified 8823 matched pairs. The incidence of AKI was 6.2% (548/8823) in the HES group and 5.6% (492/8823) in controls (odds ratio [OR], 1.12; 95% confidence interval [CI], 0.99-1.27; P = .07). Compared to controls, HES was not associated with worsening AKI stage (OR, 0.89; 95% CI, 0.79-1.01; P = .08). The incidence of RRT was lower in the HES group than that in controls (0.2% vs 0.4%, respectively; OR, 0.51; 95% CI, 0.29-0.91; P = .02). Median [interquartile range] hospital stay was 1 day longer in the HES group (12 [8-21] vs 11 [7-20] days; P < .001), but in-hospital 30-day mortality did not differ between groups (0.5% vs 0.6%, respectively: OR, 0.83; 95% CI, 0.56-1.24; P = .36). The use rate of vasoactive agents and the median net fluid requirement on the day of surgery were higher in the HES group (80.5% vs 70.0%: P < .001, 88.1 vs 73.6 mL/kg; P < .001, respectively) compared to controls. CONCLUSIONS: The present study did not demonstrate that 6% HES 130/0.4 increased the incidence and the severity of postoperative AKI. It was associated with a lower incidence of RRT when used for surgical patients.


Assuntos
Lesão Renal Aguda/prevenção & controle , Derivados de Hidroxietil Amido/química , Rim/efeitos dos fármacos , Complicações Pós-Operatórias/prevenção & controle , Pontuação de Propensão , Terapia de Substituição Renal/métodos , Lesão Renal Aguda/etiologia , Idoso , Creatinina/sangue , Estado Terminal , Bases de Dados Factuais , Feminino , Hidratação/efeitos adversos , Hidratação/métodos , Humanos , Derivados de Hidroxietil Amido/efeitos adversos , Japão , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Segurança do Paciente , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
11.
J Intensive Care Med ; 35(2): 161-169, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28934895

RESUMO

BACKGROUND: Guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) recommend euvolemia, whereas hypervolemia may cause harm. We investigated whether high early fluid input is associated with delayed cerebral ischemia (DCI), and if fluid input can be safely decreased using transpulmonary thermodilution (TPT). METHODS: We retrospectively included aSAH patients treated at an academic intensive care unit (2007-2011; cohort 1) or managed with TPT (2011-2013; cohort 2). Local guidelines recommended fluid input of 3 L daily. More fluids were administered when daily fluid balance fell below +500 mL. In cohort 2, fluid input in high-risk patients was guided by cardiac output measured by TPT per a strict protocol. Associations of fluid input and balance with DCI were analyzed with multivariable logistic regression (cohort 1), and changes in hemodynamic indices after institution of TPT assessed with linear mixed models (cohort 2). RESULTS: Cumulative fluid input 0 to 72 hours after admission was associated with DCI in cohort 1 (n=223; odds ratio [OR] 1.19/L; 95% confidence interval 1.07-1.32), whereas cumulative fluid balance was not. In cohort 2 (23 patients), using TPT fluid input could be decreased from 6.0 ± 1.0 L before to 3.4 ± 0.3 L; P = .012), while preload parameters and consciousness remained stable. CONCLUSION: High early fluid input was associated with DCI. Invasive hemodynamic monitoring was feasible to reduce fluid input while maintaining preload. These results indicate that fluid loading beyond a normal preload occurs, may increase DCI risk, and can be minimized with TPT.


Assuntos
Isquemia Encefálica/induzido quimicamente , Débito Cardíaco/fisiologia , Hidratação/efeitos adversos , Hemorragia Subaracnóidea/terapia , Equilíbrio Hidroeletrolítico/fisiologia , Estudos de Viabilidade , Feminino , Hemodinâmica , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/fisiopatologia
12.
J Surg Res ; 246: 274-283, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31614325

RESUMO

BACKGROUND: Fluid therapy influences glycocalyx shedding; however, the effect of this intervention on glycocalyx shedding in patients with glioma remains unclear. In this study, we have investigated glycocalyx shedding and cerebral metabolism during colloid loading in patients with and without glioma. METHODS: Forty patients undergoing general anesthesia were assigned to the glioma brain group (n = 20) or the normal brain group (n = 20); patients in the normal brain group were undergoing partial hepatectomy to treat liver cancer. All patients were subjected to 15 mL/kg hydroxyethyl starch (HES) loading after the induction of anesthesia. Glycocalyx shedding, reflected by syndecan-1 and heparan sulfate levels at the jugular venous bulb, was measured in both groups. We also evaluated cerebral metabolism parameters, including jugular venous oxygen saturation (SjvO2), arterial-jugular venous differences in oxygen (CajvO2), glucose (A-JvGD), lactate (A-JvLD), the cerebral extraction ratio for oxygen (CERO2), and the oxygen-glucose index. RESULTS: Our results showed that patients in the glioma brain group had lower preoperative basal syndecan-1 shedding in plasma than patients in the normal brain group. The hematocrit (Hct)-corrected syndecan-1 level was significantly increased after 15 mL/kg HES fluid administration (19.78 ± 3.83 ng/mL) compared with the Hct-correct baseline syndecan-1 level (15.67 ± 2.35 ng/mL) in patients in the glioma brain group. Similarly, for patients in the normal brain group, Hct-corrected syndecan-1 level was significantly increased after HES loading (34.71 ± 12.83 ng/mL) compared with the baseline syndecan-1 level (26.07 ± 12.52 ng/mL). However, there were no intergroup or intragroup differences in Hct-corrected heparan sulfate levels at any time point. Our study also showed that the SjvO2 was lower and CajvO2 and CERO2 were higher in the glioma brain group at 30 min after HES loading. Intragroup analysis showed that CERO2 and CajvO2 increased after general anesthesia compared with the baseline values in the glioma brain group. In contrast, cerebral metabolism in the normal brain group was unchanged during perioperative period. There were no significant differences in oxygen-glucose index between the two groups throughout the study period. CONCLUSIONS: Preoperative 15 mL/kg HES loading had similar effects on systemic glycocalyx shedding in both the glioma brain and normal brain groups, although patients in the normal brain group had higher levels of plasma syndecan-1. Furthermore, the intraoperative anesthetic management may substantially influence cerebral metabolism in patients with glioma.


Assuntos
Encéfalo/metabolismo , Hidratação/efeitos adversos , Glicocálix/efeitos dos fármacos , Derivados de Hidroxietil Amido/efeitos adversos , Cuidados Pré-Operatórios/efeitos adversos , Adulto , Encéfalo/efeitos dos fármacos , Encéfalo/cirurgia , Neoplasias Encefálicas/metabolismo , Neoplasias Encefálicas/cirurgia , Endotélio Vascular/citologia , Endotélio Vascular/efeitos dos fármacos , Endotélio Vascular/metabolismo , Feminino , Hidratação/métodos , Glioma/metabolismo , Glioma/cirurgia , Glicocálix/metabolismo , Heparitina Sulfato/análise , Heparitina Sulfato/metabolismo , Humanos , Derivados de Hidroxietil Amido/administração & dosagem , Cuidados Intraoperatórios/efeitos adversos , Cuidados Intraoperatórios/métodos , Veias Jugulares/química , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Sindecana-1/sangue , Sindecana-1/metabolismo
13.
J Infect Dis ; 221(2): 285-292, 2020 01 02.
Artigo em Inglês | MEDLINE | ID: mdl-31504666

RESUMO

BACKGROUND: Liberal fluid resuscitation has proved harmful in adults with severe malaria, but the level of restriction has not been defined. METHODS: In a prospective observational study in adults with severe falciparum malaria, restrictive fluid management was provided at the discretion of the treating physician. The relationships between the volume of fluid and changes in renal function or tissue perfusion were evaluated. RESULTS: A total of 154 patients were studied, 41 (26.6%) of whom died. Median total fluid intake during the first 6 and 24 hours from enrollment was 3.3 (interquartile range [IQR], 1.8-5.1) mL/kg per hour and 2.2 (IQR, 1.6-3.2) mL/kg per hour, respectively. Total fluid intake at 6 hours was not correlated with changes in plasma creatinine at 24 hours (n = 116; rs = 0.16; P = .089) or lactate at 6 hours (n = 94; rs = -0.05; P = .660). Development of hypotensive shock or pulmonary edema within 24 hours after enrollment were not related to the volume of fluid administration. CONCLUSIONS: Restrictive fluid management did not worsen kidney function and tissue perfusion in adult patients with severe falciparum malaria. We suggest crystalloid administration of 2-3 mL/kg per hour during the first 24 hours without bolus therapy, unless the patient is hypotensive.


Assuntos
Hidratação/métodos , Malária Falciparum/tratamento farmacológico , Lesão Renal Aguda/etiologia , Adulto , Feminino , Hidratação/efeitos adversos , Humanos , Testes de Função Renal , Ácido Láctico/sangue , Malária Falciparum/mortalidade , Masculino , Estudos Prospectivos , Edema Pulmonar/etiologia , Adulto Jovem
14.
J Trop Pediatr ; 66(2): 152-162, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-31280298

RESUMO

BACKGROUND: Fluid overload (FO) has been accused as being one of the ICU problems affecting morbidity and mortality. The aim of the study was to assess the effect and critical threshold of FO that is related to mortality. METHODS: This prospective observational study was conducted in a pediatric ICU. All patients admitted (n = 203) during 12 months with a length of stay more than 48 h were recruited. RESULTS: FO was found to be related to mortality (p = 0.025) but was not proved to be an independent risk factor of fatal outcome by the logistic regression model. This raises the suspicion about any cause-effect relationship between FO and mortality. Even though, FO was statistically a fair discriminator of death (AUC = 0.655, p = 0.0008) and a cutoff level of FO was set at 7%. Kaplan-Meier curve showed that cumulative of survival differed significantly between groups of patients with FO more and less than 7% (p = 0.002). CONCLUSION: Frequent and accurate monitoring of FO is crucial among critically ill patients. The present study suggested a threshold of 7% FO beyond which a more conservative regimen of fluid administration might improve patients' outcome.


Assuntos
Estado Terminal/mortalidade , Hidratação/efeitos adversos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Criança , Pré-Escolar , Feminino , Hidratação/mortalidade , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Estimativa de Kaplan-Meier , Masculino , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Desequilíbrio Hidroeletrolítico/etiologia , Desequilíbrio Hidroeletrolítico/mortalidade
15.
Catheter Cardiovasc Interv ; 95(5): 895-903, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-31282129

RESUMO

BACKGROUND: Urine flow rate (UFR)-guided and left-ventricular end-diastolic pressure (LVEDP)-guided hydration regimens have been proposed to prevent contrast-induced acute kidney injury (CIAKI). The REnal Insufficiency Following Contrast MEDIA Administration triaL III (REMEDIAL III) is a randomized, multicenter, investigator-sponsored trial aiming to compare these two hydration strategies. METHODS: Patients at high risk for CIAKI (that is, those with estimated glomerular filtration rate ≤ 45 mL/min/1.73 m2 and/or with Mehran's score ≥11 and/or Gurm's score >7) will be enrolled. Patients will be randomly assigned to (a) LVEDP-guided hydration with normal saline (LVEDP-guided group) and (b) UFR-guided hydration carried out by the RenalGuard system (RenalGuard group). Seven-hundred patients (350 in each arm) will be enrolled. In the LVEDP-guided group the fluid infusion rate will be adjusted according to the LVEDP as follows: 5 mL kg-1 hr-1 for LVEDP ≤12 mmHg, 3 mL kg-1 hr-1 for LVEDP 13-18 mmHg, and 1.5 mL kg-1 hr-1 for LVEDP >18 mmHg. In the RenalGuard group hydration with normal saline plus low-dose of furosemide is controlled by the RenalGuard system, in order to reach and maintain a high (>300 mL/hr) UFR. In all cases, iobitridol (a low-osmolar, nonionic contrast agent) will be administered. RESULTS: The primary endpoint is the composite of CIAKI (i.e., serum creatinine increase ≥25% and/or ≥0.5 mg/dL from the baseline to 48 hr after contrast media exposure) and/or acute pulmonary edema. CONCLUSION: The REMEDIAL III will test the hypothesis that the UFR-guided hydration is superior to the LVEDP-guided hydration to prevent the composite of CIAKI and/or acute pulmonary edema.


Assuntos
Lesão Renal Aguda/prevenção & controle , Meios de Contraste/efeitos adversos , Hidratação , Iohexol/análogos & derivados , Rim/efeitos dos fármacos , Solução Salina/administração & dosagem , Urodinâmica , Função Ventricular Esquerda , Remodelação Ventricular , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/fisiopatologia , Idoso , Meios de Contraste/administração & dosagem , Feminino , Hidratação/efeitos adversos , Humanos , Iohexol/administração & dosagem , Iohexol/efeitos adversos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Valor Preditivo dos Testes , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Solução Salina/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
16.
Cardiovasc Revasc Med ; 21(1): 20-23, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31378387

RESUMO

BACKGROUND: Intravenous fluid (IVF) administration for the prevention of contrast-induced nephropathy (CIN) is considered standard of care, but the effect of IVF therapy on longer-term outcomes after radiocontrast dye administration is not well known. METHODS AND RESULTS: We studied 4367 patients undergoing coronary and peripheral angiography and intervention at a veterans' administration medical center. 2653 patients (61%) received IVF prior to the procedure and 1714 (39%) did not. Of the 4367 subjects 1962 (45%) had repeat creatinine values at 72 h and 3100 (70%) had repeat creatinine values at 3 months. CIN at 72 h occurred in 68 (6.7%) patients in the IVF group and in 87 patients (9.8%) in the group receiving no IVF (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.94-0.99; p = 0.004). At 3 months, renal dysfunction was seen in 224 (11.5%) patients of the IVF group versus 152 (13.1%) of the group receiving no IVF (OR 0.98, CI 0.96-1.01; p = 0.18). In adjusted analyses using a propensity score, IVF therapy was associated with a significant reduction in CIN occurrence at 72 h (OR = 0.97, (95% CI 0.94-0.99, p = 0.01) but was not associated with a change in the incidence of renal dysfunction at 3 months (OR 0.98, 95% CI 0.96-1.01. p = 0.18). CONCLUSION: In this cohort of US veterans, IVF administration was associated with a decreased incidence of CIN at 72 h but was not associated with a decreased incidence of renal dysfunction at 3 months.


Assuntos
Lesão Renal Aguda/prevenção & controle , Cateterismo Cardíaco/efeitos adversos , Cateterismo Periférico/efeitos adversos , Meios de Contraste/efeitos adversos , Angiografia Coronária/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Hidratação , Rim/efeitos dos fármacos , Solução Salina/administração & dosagem , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/fisiopatologia , Idoso , Meios de Contraste/administração & dosagem , Feminino , Hidratação/efeitos adversos , Humanos , Incidência , Infusões Intravenosas , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fatores de Proteção , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Solução Salina/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Serviços de Saúde para Veteranos Militares
17.
J Surg Res ; 247: 350-355, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31676145

RESUMO

BACKGROUND: Trauma is the leading cause of death among children. Studies have found that insufficient intravenous (IV) fluid resuscitation contributes significantly to morbidity and mortality in pediatric trauma. While large-volume resuscitation represents a potential solution, overly aggressive fluid management may complicate hospitalizations and recovery. Through this study, we aim to evaluate the impact of aggressive fluid resuscitation on outcomes in pediatric trauma. MATERIALS AND METHODS: This is a retrospective review utilizing our level I trauma center registry for pediatric patients aged <16 y admitted from 2014 to 2017. Patients transferred from our center within 24 h and those who arrived from outside hospitals were excluded. Patients who received blood product transfusions were excluded. Included patients were divided into two crystalloid groups: <60 mL/kg/24 h and ≥60 mL/kg/24 h. Outcome measures included ICU length-of-stay, length-of-hospitalization, complications, and mortality rate. RESULTS: Study sample included 320 patients (<60 mL/kg/24 h = 219; ≥60 mL/kg/24 h = 101). The ≥60 mL/kg/24 h group was younger (9.95 versus 5.27, P = 0.0001). There were no significant differences in GCS on arrival, injury severity score, Abbreviated Injury Scale, Revised Trauma Scores, traumatic brain injury, and operative intervention between groups. Outcome measures showed there was no significant difference in 30-day readmission rate, complications, or mortality. Large-volume crystalloid resuscitation was associated with longer mean ICU length-of-stay (1.5 d versus 0.8 d, P = 0.004). CONCLUSIONS: In this single-institution retrospective database analysis, large-volume crystalloid resuscitation (≥60 mL/kg) was associated with a significant increase in ICU length-of-stay without survival benefit. More research in the form of randomized trials will help determine the optimal rate for fluid resuscitation in pediatric trauma patients while weighing potential critical care complications.


Assuntos
Soluções Cristaloides/administração & dosagem , Hidratação/métodos , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Escala Resumida de Ferimentos , Adolescente , Criança , Pré-Escolar , Soluções Cristaloides/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Hidratação/efeitos adversos , Hidratação/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Sistema de Registros/estatística & dados numéricos , Ressuscitação/efeitos adversos , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade
18.
Ann Vasc Surg ; 65: 282.e9-282.e11, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31676383

RESUMO

Intraosseous (IO) needles are used in patients who are critically ill when it is not possible to obtain venous access. While IO allows for immediate access, IO infusions are associated with complications including fractures, infections, and compartment syndrome. We present a case of an 87-year-old man who developed lower extremity compartment syndrome after receiving an IO needle insertion and had to be treated surgically with fasciotomy to correct the problem.


Assuntos
Síndromes Compartimentais/etiologia , Hidratação/efeitos adversos , Infusões Intraósseas/efeitos adversos , Tíbia , Idoso de 80 Anos ou mais , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/cirurgia , Fasciotomia , Hidratação/instrumentação , Humanos , Infusões Intraósseas/instrumentação , Masculino , Agulhas , Resultado do Tratamento
19.
Anesth Analg ; 130(3): 752-761, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31651455

RESUMO

BACKGROUND: In patients in the prone position, the reliability of pulse pressure variation and stroke volume variation (PPV and SVV) and the use of functional hemodynamic tests to predict fluid responsiveness have not previously been established. Perioperatively, in this setting, optimizing fluid management can be challenging, and fluid overload is associated with both intraoperative and postoperative complications. We designed this study to assess the sensitivity and specificity of baseline PPV and SVV, the tidal volume (VT) challenge (VTC) and the end-expiratory occlusion test (EEOT) in predicting fluid responsiveness during elective spinal surgery. METHODS: The study protocol was started during a period of intraoperative hemodynamic stability after prone positioning and before the administration of any vasopressor: (1) at baseline, the controlled ventilation was set at 6 mL/kg of predicted body weight (PBW) (T0); (2) patients underwent the first EEOT (EEOT6) by interrupting the mechanical ventilation for 30 seconds; (3) the ventilation was set again at 6 mL/kg PBW for 1 minute (T1); (4) the VTC was applied by increasing the VT up to 8 mL/kg PBW for 1 minute; (5) the ventilation was kept at 8 mL/kg PBW for 1 minute (T2); (6) a second EEOT (EEOT8) was performed; (7) the VT was reduced back to 6 mL/kg PBW for 1 minute (T3); (8) a fluid challenge of 250 mL of Ringer's solution was infused over 10 minutes. After each step, a complete set of hemodynamic measurements was recorded. RESULTS: Neither PPV and SVV values recorded at T3 nor the EEOT6 or the EEOT8 predicted fluid responsiveness. The change in PPV after VTC application predicted fluid responsiveness with an area under the curve of 0.96 (95% confidence interval, 0.87-1.00), showing a sensitivity of 95.2% and a specificity of 94.7%, using a cutoff increase of 12.2%. The change in SVV after VTC application predicted fluid responsiveness with an area under the curve 0.96 (95% confidence interval, 0.89-1.00) showing a sensitivity of 95.2% and a specificity of 94.7%, using a cutoff increase of 8.0%. A linear correlation between stroke volume index changes after fluid challenge administration and the changes in PPV and SVV after VTC application was observed (r = 0.71; P < .0001 and r = 0.68; P < .0001, respectively). CONCLUSIONS: In prone elective neurosurgical patients, the baseline values of PPV and SVV and the EEOT fail to predict fluid responsiveness, while the VTC is a very reliable functional hemodynamic test and could be helpful in guiding intraoperative fluid therapy.


Assuntos
Hidratação , Hemodinâmica , Monitorização Intraoperatória/métodos , Procedimentos Neurocirúrgicos , Posicionamento do Paciente , Decúbito Ventral , Respiração Artificial , Mecânica Respiratória , Solução de Ringer/administração & dosagem , Coluna Vertebral/cirurgia , Idoso , Pressão Sanguínea , Tomada de Decisão Clínica , Feminino , Hidratação/efeitos adversos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Posicionamento do Paciente/efeitos adversos , Assistência Perioperatória , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Respiração Artificial/efeitos adversos , Solução de Ringer/efeitos adversos , Fatores de Risco , Volume Sistólico , Volume de Ventilação Pulmonar , Fatores de Tempo
20.
Transplantation ; 104(7): 1419-1428, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31644490

RESUMO

BACKGROUND: Liver transplant recipients suffer many postoperative complications. Few studies evaluated the effects of fluid management on these complications. We conducted an observational cohort study to evaluate the association between intraoperative fluid balance and postoperative acute kidney injury (AKI) and other postoperative complications. METHODS: We included consecutive adult liver transplant recipients who had their surgery between July 2008 and December 2017. Our exposure was intraoperative fluid balance, and our primary outcome was the grade of AKI at 48 hours after surgery. Our secondary outcomes were the grade of AKI at 7 days, the need for postoperative renal replacement therapy, postoperative red blood cell transfusions, time to first extubation, time to discharge from the intensive care unit (ICU), and 1-year survival. Every analysis was adjusted for potential confounders. RESULTS: We included 532 transplantations in 492 patients. We observed no effect of fluid balance on either 48-hour AKI, 7-day AKI, or on the need for postoperative renal replacement therapy after adjustments for confounders. A higher fluid balance increased the time to ICU discharge, and increased the risk of dying (hazard ratio = 1.21 [1.04,1.40]). CONCLUSIONS: We observed no association between intraoperative fluid balance and postoperative AKI. Fluid balance was associated with longer time to ICU discharge and lower survival. This study provides insight that might inform the design of a clinical trial on fluid management strategies in this population.


Assuntos
Lesão Renal Aguda/epidemiologia , Doença Hepática Terminal/cirurgia , Hidratação/efeitos adversos , Cuidados Intraoperatórios/efeitos adversos , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/fisiopatologia , Lesão Renal Aguda/terapia , Adulto , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/fisiopatologia , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Hidratação/métodos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados Intraoperatórios/métodos , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Terapia de Substituição Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Equilíbrio Hidroeletrolítico/fisiologia
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