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1.
PLoS One ; 15(10): e0241028, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33091034

RESUMO

INTRODUCTION: An increase in the incidence of OHCA during the COVID-19 pandemic has been recently demonstrated. However, there are no data about how the COVID-19 epidemic influenced the treatment of OHCA victims. METHODS: We performed an analysis of the Lombardia Cardiac Arrest Registry comparing all the OHCAs occurred in the Provinces of Lodi, Cremona, Pavia and Mantua (northern Italy) in the first 100 days of the epidemic with those occurred in the same period in 2019. RESULTS: The OHCAs occurred were 694 in 2020 and 520 in 2019. Bystander cardiopulmonary resuscitation (CPR) rate was lower in 2020 (20% vs 31%, p<0.001), whilst the rate of bystander automated external defibrillator (AED) use was similar (2% vs 4%, p = 0.11). Resuscitation was attempted by EMS in 64.5% of patients in 2020 and in 72% in 2019, whereof 45% in 2020 and 64% in 2019 received ALS. At univariable analysis, the presence of suspected/confirmed COVID-19 was not a predictor of resuscitation attempt. Age, unwitnessed status, non-shockable presenting rhythm, absence of bystander CPR and EMS arrival time were independent predictors of ALS attempt. No difference regarding resuscitation duration, epinephrine and amiodarone administration, and mechanical compression device use were highlighted. The return of spontaneous circulation (ROSC) rate at hospital admission was lower in the general population in 2020 [11% vs 20%, p = 0.001], but was similar in patients with ALS initiated [19% vs 26%, p = 0.15]. Suspected/confirmed COVID-19 was not a predictor of ROSC at hospital admission. CONCLUSION: Compared to 2019, during the 2020 COVID-19 outbreak we observed a lower attitude of laypeople to start CPR, while resuscitation attempts by BLS and ALS staff were not influenced by suspected/confirmed infection, even at univariable analysis.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Serviços Médicos de Emergência , Parada Cardíaca Extra-Hospitalar/terapia , Pneumonia Viral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Amiodarona/administração & dosagem , Reanimação Cardiopulmonar , Infecções por Coronavirus/virologia , Desfibriladores , Epinefrina/administração & dosagem , Feminino , Humanos , Incidência , Itália , Estudos Longitudinais , Masculino , Pandemias , Pneumonia Viral/virologia , Estudos Prospectivos , Sistema de Registros , Fatores de Tempo , Vasoconstritores/administração & dosagem , Vasodilatadores/administração & dosagem
2.
Emerg Med Clin North Am ; 38(4): 755-769, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32981615

RESUMO

There are approximately 350,000 out-of-hospital cardiac arrests and 200,000 in-hospital cardiac arrests annually in the United States, with survival rates of approximately 5% to 10% and 24%, respectively. The critical factors that have an impact on cardiac arrest survival include prompt recognition and activation of prehospital care, early cardiopulmonary resuscitation, and rapid defibrillation. Advanced life support protocols are continually refined to optimize intracardiac arrest management and improve survival with favorable neurologic outcome. This article focuses on current treatment recommendations for adult nontraumatic cardiac arrest, with emphasis on the latest evidence and controversies regarding intracardiac arrest management.


Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca/terapia , Manuseio das Vias Aéreas , Antiarrítmicos/administração & dosagem , Pressão Sanguínea , Dióxido de Carbono/análise , Diástole , Ecocardiografia , Cardioversão Elétrica , Serviço Hospitalar de Emergência , Epinefrina/administração & dosagem , Humanos , Hipotermia Induzida , Infusões Intraósseas , Infusões Intravenosas , Monitorização Fisiológica , Sistemas Automatizados de Assistência Junto ao Leito , Guias de Prática Clínica como Assunto , Vasoconstritores/administração & dosagem
6.
Arch Gynecol Obstet ; 302(4): 829-836, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32588134

RESUMO

OBJECTIVE: To investigate the efficacy and safety of prophylactic infusion of norepinephrine (NE) versus normal saline in patients undergoing cesarean section. METHODS: Patients (n = 97) were randomized to receive a bolus of NE (6 µg) immediately following spinal anesthesia with maintenance NE (0.05 µg/kg/min IV) or normal saline (n = 98). The primary endpoint was the incidence of postspinal anesthesia hypotension [systolic blood pressure (SBP) < 80% of baseline] at 1-20 min following spinal anesthesia. Secondary outcomes were the overall stability of SBP control versus baseline, inferior vena cava collapsibility index (IVC-CI), other adverse events (bradycardia, nausea, vomiting, and hypertension), and neonatal outcomes (blood gas values and Apgar scores). RESULTS: The rates of postspinal anesthesia hypotension and severe postspinal anesthesia hypotension (SBP < 60% of the baseline) were significantly lower in the NE group (17.5% vs. 62.2%, p < 0.001; 7.2% vs. 17.4%, p = 0.031). In the NE group, SBP remained more stable and closer to baseline (p < 0.001), and IVC-CI values were lower 5 min after spinal anesthesia and 5 min after fetal delivery (p = 0.045; p < 0.001, respectively). Other adverse effects and neonatal outcomes were not different between the two groups. CONCLUSION: Prophylactic NE infusion effectively lowers the incidence of postspinal anesthesia hypotension and does not increase other adverse events in patients or neonates.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea/efeitos adversos , Hipotensão/prevenção & controle , Infusões Parenterais/efeitos adversos , Norepinefrina/administração & dosagem , Profilaxia Pré-Exposição/métodos , Vasoconstritores/administração & dosagem , Adulto , Anestesia Obstétrica/métodos , Raquianestesia/métodos , Pressão Sanguínea , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Cesárea/métodos , China/epidemiologia , Feminino , Humanos , Hipertensão/induzido quimicamente , Hipertensão/complicações , Hipotensão/epidemiologia , Recém-Nascido , Infusões Parenterais/métodos , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Náusea/epidemiologia , Norepinefrina/efeitos adversos , Gravidez , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vômito/induzido quimicamente , Vômito/epidemiologia , Adulto Jovem
7.
PLoS One ; 15(5): e0232830, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32407353

RESUMO

During general anesthesia (GA), direct analysis of arterial pressure or aortic flow waveforms may be inconclusive in complex situations. Patient-specific biomechanical models, based on data obtained during GA and capable to perform fast simulations of cardiac cycles, have the potential to augment hemodynamic monitoring. Such models allow to simulate Pressure-Volume (PV) loops and estimate functional indicators of cardiovascular (CV) system, e.g. ventricular-arterial coupling (Vva), cardiac efficiency (CE) or myocardial contractility, evolving throughout GA. In this prospective observational study, we created patient-specific biomechanical models of heart and vasculature of a reduced geometric complexity for n = 45 patients undergoing GA, while using transthoracic echocardiography and aortic pressure and flow signals acquired in the beginning of GA (baseline condition). If intraoperative hypotension (IOH) appeared, diluted norepinephrine (NOR) was administered and the model readjusted according to the measured aortic pressure and flow signals. Such patients were a posteriori assigned into a so-called hypotensive group. The accuracy of simulated mean aortic pressure (MAP) and stroke volume (SV) at baseline were in accordance with the guidelines for the validation of new devices or reference measurement methods in all patients. After NOR administration in the hypotensive group, the percentage of concordance with 10% exclusion zone between measurement and simulation was >95% for both MAP and SV. The modeling results showed a decreased Vva (0.64±0.37 vs 0.88±0.43; p = 0.039) and an increased CE (0.8±0.1 vs 0.73±0.11; p = 0.042) in hypotensive vs normotensive patients. Furthermore, Vva increased by 92±101%, CE decreased by 13±11% (p < 0.001 for both) and contractility increased by 14±11% (p = 0.002) in the hypotensive group post-NOR administration. In this work we demonstrated the application of fast-running patient-specific biophysical models to estimate PV loops and functional indicators of CV system using clinical data available during GA. The work paves the way for model-augmented hemodynamic monitoring at operating theatres or intensive care units to enhance the information on patient-specific physiology.


Assuntos
Anestesia Geral/métodos , Pressão Arterial/fisiologia , Débito Cardíaco/fisiologia , Monitorização Hemodinâmica/métodos , Hipotensão/fisiopatologia , Modelos Cardiovasculares , Volume Sistólico/fisiologia , Algoritmos , Fenômenos Biomecânicos , Pressão Sanguínea , Feminino , Humanos , Hipotensão/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Estudo de Prova de Conceito , Estudos Prospectivos , Vasoconstritores/administração & dosagem
8.
J Trauma Acute Care Surg ; 88(6): 783-788, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32459446

RESUMO

BACKGROUND: Delayed graft function (DGF), the need for dialysis in the first week following kidney transplant, affects approximately one quarter of deceased-donor kidney transplant recipients. Donor demographics, donor serum creatinine, and graft cold ischemia time are associated with DGF. However, there is no consensus on the optimal management of hemodynamic instability in organ donors after brain death (DBDs). Our objective was to determine the relationship between vasopressor selection during donor management and the development of DGF. METHODS: Prospective observational data, including demographic and critical care parameters, were collected for all DBDs managed by 17 organ procurement organizations from nine Organ Procurement and Transplantation Network Regions between 2012 and 2018. Recipient outcome data were linked with donor data through donor identification numbers. Donor critical care parameters, including type of vasopressor and doses, were recorded at three standardized time points during donor management. The analysis included only donors who received at least one vasopressor at all three time points. Vasopressor doses were converted to norepinephrine equivalent doses and analyzed as continuous variables. Univariate analyses were conducted to determine the association between donor variables and DGF. Results were adjusted for known predictors of DGF using binary logistic regression. RESULTS: Complete data were available for 5,554 kidney transplant recipients and 2,985 DBDs. On univariate analysis, donor serum creatinine, donor age, donor subtype, kidney donor profile index, graft cold ischemia time, phenylephrine dose, and dopamine dose were associated with DGF. After multivariable analysis, increased donor serum creatinine, donor age, kidney donor profile index, graft cold ischemia time, and phenylephrine dose remained independent predictors of DGF. CONCLUSION: Higher doses of phenylephrine were an independent predictor of DGF. With the exception of phenylephrine, the selection and dose of vasopressor during donor management did not predict the development of DGF. LEVEL OF EVIDENCE: Prognostic study, Level III.


Assuntos
Morte Encefálica/fisiopatologia , Cuidados Críticos/estatística & dados numéricos , Função Retardada do Enxerto/epidemiologia , Transplante de Rim/efeitos adversos , Rim/efeitos dos fármacos , Vasoconstritores/efeitos adversos , Adulto , Fatores Etários , Isquemia Fria/efeitos adversos , Cuidados Críticos/métodos , Função Retardada do Enxerto/etiologia , Função Retardada do Enxerto/prevenção & controle , Relação Dose-Resposta a Droga , Feminino , Humanos , Rim/irrigação sanguínea , Rim/fisiopatologia , Transplante de Rim/métodos , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Fenilefrina/administração & dosagem , Fenilefrina/efeitos adversos , Estudos Prospectivos , Medição de Risco , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Vasoconstritores/administração & dosagem , Adulto Jovem
9.
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
10.
J Card Surg ; 35(6): 1228-1236, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32333454

RESUMO

BACKGROUND: Cardiac surgery using cardiopulmonary bypass is a well-established procedure. However, up to 20% to 30% of patients require high dose vasopressor or inotropic support following surgery, enhancing the risk of organ dysfunction and impacting mortality. Nonalcoholic fatty liver disease (NAFLD) is a frequent finding in these patients and may be involved in the pathophysiology of vasoplegia and cardiac failure. METHODS: Retrospective analysis of 463 patients undergoing elective cardiac surgery in 2014 at our institution. NAFLD was defined using the NAFLD fibrosis score and the vasoactive-inotropy score was used to determine postoperative vasopressor and inotropic dependency. RESULTS: Patients with NAFLD more often presented with high vasopressor or inotropic support compared to patients without NAFLD, resulting in significant differences after 6 hours (n = 20 [27.0%] of 74 patients), 12 hours (n = 20 [27.0%] of 74 patients), and on the first postoperative day (n = 12 [16.4%] of 73 patients) of intensive care unit (ICU) treatment. Multivariate analysis revealed time of catecholamine application (P = .001), preoperative left ventricular ejection fraction (P = .001), type of surgery (P = .001), model of endstage liver disease on hospital admission (P = .002), pre-existing pulmonary hypertension (P = .004) and NAFLD-time interaction (P = .05) as independent predictors of high vasopressor and inotropic support. Patients with NAFLD had higher degrees of extrahepatic organ dysfunction, were more dependent on hemodialysis, spent more days in the ICU and within the hospital. Patients with NAFLD and high catecholamine support had the highest mortality rates among the study population. CONCLUSIONS: NAFLD is a common finding in elective cardiac surgery patients. Anesthesiologists and intensivists should be sensitive for the specific risk profile of this population.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Catecolaminas/administração & dosagem , Catecolaminas/efeitos adversos , Hepatopatias/etiologia , Complicações Pós-Operatórias/etiologia , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Cardiotônicos/administração & dosagem , Cardiotônicos/efeitos adversos , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/complicações , Período Pós-Operatório , Estudos Retrospectivos , Risco , Volume Sistólico , Vasoplegia/etiologia , Função Ventricular Esquerda
11.
Acta Orthop Traumatol Turc ; 54(2): 132-137, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32254027

RESUMO

OBJECTIVE: This study aimed to determine whether the local administration of tranexamic acid (TXA) combined with diluted epinephrine (DEP) reduces blood loss and the need for transfusions compared with the administration of TXA alone following surgery for trochanteric femoral fractures. METHODS: Hundred patients were enrolled in this study. In the target group (TXA/DEP group: n=50; 19 men and 31 women, mean age 72.5±11.1 years), the surgical sites were injected with 35 mL normal saline mixed with 3 g of TXA with 0.2 mg of DEP at a 1:200,000 dilution (TXA/DEP) immediately after musculoaponeurotic closure. In the control group (TXA group: n=50; 22 men and 28 women; mean age: 70.5±12.2 years), the surgical site was injected with 35 mL normal saline containing 3 g of TXA alone. The main outcome measures were postoperative hemoglobin (Hb) levels, hematocrit, drainage volume, and total blood loss (TBL); the secondary measures included transfusion requirements and perioperative complications. RESULTS: The mean Hb levels among patients in theTXA/DEP group were significantly lower than among those in the TXA group, measured on postoperative day 1 at 101.0±14.1 g/L vs. 106.9±10.5 g/L and day 3 as 104.2±8.2 g/L vs. 108.5±9.1 g/L, respectively (p<0.05). Drainage volume from the surgical site and TBL measured on postoperative day 2 were also significantly reduced in the TXA/DEP group vs. the TXA group, measured at 71.4±26.0 mL vs. 82.5±24.6 mL and 343.6±148.0 mL vs. 419.6±165.4 mL, respectively (p<0.05). Furthermore, 11 patients (22%) from the TXA group and 15 (30%) from the TXA/DEP group received blood transfusions; the mean number of transfusion events (1.2±0.4 vs. 1.9±0.7) and the amount of blood transfused (1.7±0.5 Units vs. 2.9±1.0 Units) was also markedly reduced in the TXA/DEP group (p<0.05). Two cases in the TXA/DEP group and three in the TXA group were diagnosed with deep vein thrombosis, a difference that did not reach statistical significance (p>0.05). CONCLUSION: Local administration of TXA with DEP reduced blood loss and limited the need for blood transfusions after surgery for trochanteric femoral fracture without increasing the risk of perioperative complications. Our study indicates that the local administration of TXA/DEP is safe and more effective than the administration of TXA alone in treating trochanteric femoral fractures. LEVEL OF EVIDENCE: Level III, Therapeutic study.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Epinefrina/administração & dosagem , Fixação de Fratura/efeitos adversos , Fraturas do Quadril/cirurgia , Hemorragia Pós-Operatória/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Idoso , Antifibrinolíticos/administração & dosagem , Transfusão de Sangue/estatística & dados numéricos , Feminino , Fixação de Fratura/métodos , Humanos , Masculino , Resultado do Tratamento , Vasoconstritores/administração & dosagem
12.
Circ Cardiovasc Interv ; 13(4): e008587, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32279562

RESUMO

BACKGROUND: Intracoronary acetylcholine (Ach) provocation testing is the gold standard for assessing coronary endothelial function. However, dosing regimens of Ach are quite varied in the literature, and there are limited data evaluating the optimal dose. We evaluated the dose-response relationship between Ach and minimal lumen diameter (MLD) by sex and studied whether incremental intracoronary Ach doses given during endothelial function testing improve its diagnostic utility. METHODS: We evaluated 65 men and 212 women with angina and no obstructive coronary artery disease who underwent endothelial function testing using the highest tolerable dose of intracoronary Ach, up to 200 µg. Epicardial endothelial dysfunction was defined as a decrease in MLD >20% after intracoronary Ach by quantitative coronary angiography. We used a linear mixed effects model to evaluate the dose-response relationship. Deming regression analysis was done to compare the %MLD constriction after incremental doses of intracoronary Ach. RESULTS: The mean age was 53.5 years. Endothelial dysfunction was present in 186 (68.1%). Among men with endothelial dysfunction, there was a significant decrease in MLD/10 µg of Ach at doses above 50 µg and 100 µg, while this decrease in MLD was not observed in women (P<0.001). The %MLD constriction at 20 µg versus 50 µg and 50 µg versus 100 µg were not equivalent while the %MLD constriction at 100 µg versus 200 µg were equivalent. CONCLUSIONS: Women and men appear to have different responses to Ach during endothelial function testing. In addition to having a greater response to intracoronary Ach at all doses, men also demonstrate an Ach-MLD dose-response relationship with doses up to 200 µg, while women have minimal change in MLD with doses above 50 µg. An incremental dosing regimen during endothelial function testing appears to improve the diagnostic utility of the test and should be adjusted based on the sex of the patient.


Assuntos
Acetilcolina/administração & dosagem , Angina Pectoris/diagnóstico por imagem , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Vasoespasmo Coronário/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Endotélio Vascular/fisiopatologia , Vasoconstrição , Vasoconstritores/administração & dosagem , Adulto , Idoso , Angina Pectoris/fisiopatologia , Doença da Artéria Coronariana/fisiopatologia , Vasoespasmo Coronário/induzido quimicamente , Vasoespasmo Coronário/fisiopatologia , Vasos Coronários/fisiopatologia , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores Sexuais
13.
Clin Sci (Lond) ; 134(5): 513-527, 2020 03 13.
Artigo em Inglês | MEDLINE | ID: mdl-32104886

RESUMO

An important link exists between hypertension and inflammation. Hypertensive patients present elevated circulating levels of proinflammatory cytokines, including interleukin-17A (IL-17A). This cytokine participates in host defense, autoimmune and chronic inflammatory pathologies, and cardiovascular diseases, mainly through the regulation of proinflammatory factors. Emerging evidence also suggests that IL-17A could play a role in regulating blood pressure and end-organ damage. Here, our preclinical studies in a murine model of systemic IL-17A administration showed that increased levels of circulating IL-17A raised blood pressure induced inward remodeling of small mesenteric arteries (SMAs) and arterial stiffness. In IL-17A-infused mice, treatment with hydralazine and hydrochlorothiazide diminished blood pressure elevation, without modifying mechanical and structural properties of SMA, suggesting a direct vascular effect of IL-17A. The mechanisms of IL-17A seem to involve an induction of vascular smooth muscle cell (VSMC) hypertrophy and phenotype changes, in the absence of extracellular matrix (ECM) proteins accumulation. Accordingly, treatment with an IL-17A neutralizing antibody diminished SMA remodeling in a model of angiotensin II (Ang II) infusion. Moreover, in vitro studies in VSMCs reported here, provide further evidence of the direct effects of IL-17A on cell growth responses. Our experimental data suggest that IL-17A is a key mediator of vascular remodeling of the small arteries, which might contribute, at least in part, to blood pressure elevation.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Interleucina-17/farmacologia , Artérias Mesentéricas/efeitos dos fármacos , Remodelação Vascular/efeitos dos fármacos , Angiotensina II/administração & dosagem , Angiotensina II/farmacologia , Animais , Forma Celular/efeitos dos fármacos , Humanos , Hipertensão/fisiopatologia , Interleucina-17/administração & dosagem , Masculino , Artérias Mesentéricas/fisiologia , Camundongos Endogâmicos C57BL , Músculo Liso Vascular , Miócitos de Músculo Liso/citologia , Miócitos de Músculo Liso/efeitos dos fármacos , Vasoconstritores/administração & dosagem , Vasoconstritores/farmacologia
14.
Crit Care ; 24(1): 52, 2020 02 14.
Artigo em Inglês | MEDLINE | ID: mdl-32059682

RESUMO

BACKGROUND: Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock. METHODS: A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period. They were classified into very-early (VE-VPs) or delayed vasopressor start (D-VPs) categories according to whether norepinephrine was initiated or not within/before the next hour of the first resuscitative fluid load. Then, VE-VPs (n = 93) patients were 1:1 propensity matched to D-VPs (n = 93) based on age; source of admission (emergency room, general wards, intensive care unit); chronic and acute comorbidities; and lactate, heart rate, systolic, and diastolic pressure at vasopressor start. A risk-adjusted Cox proportional hazard model was fitted to assess the association between VE-VPs and day 28 mortality. Finally, a sensitivity analysis was performed also including those patients requiring VP support for less than 6 h. RESULTS: Patients subjected to VE-VPs received significantly less resuscitation fluids at vasopressor starting (0[0-510] vs. 1500[650-2300] mL, p < 0.001) and during the first 8 h of resuscitation (1100[500-1900] vs. 2600[1600-3800] mL, p < 0.001), with no significant increase in acute renal failure and/or renal replacement therapy requirements. VE-VPs was related with significant lower net fluid balances 8 and 24 h after VPs. VE-VPs was also associated with a significant reduction in the risk of death compared to D-VPs (HR 0.31, CI95% 0.17-0.57, p < 0.001) at day 28. Such association was maintained after including patients receiving vasopressors for < 6 h. CONCLUSION: A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes.


Assuntos
Hidratação , Norepinefrina , Choque Séptico , Vasoconstritores , Lesão Renal Aguda/complicações , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Terapia de Substituição Renal , Choque Séptico/tratamento farmacológico , Fatores de Tempo , Vasoconstritores/administração & dosagem
15.
Plast Reconstr Surg ; 145(3): 737-744, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32097317

RESUMO

BACKGROUND: Open carpal tunnel release is commonly performed with the use of a tourniquet. The combination of local anesthetic and epinephrine with a pneumatic tourniquet helps provide clear visualization during decompression of the median nerve. There has been a rapid expansion of literature challenging the use of tourniquets in open carpal tunnel release. Consequently, the local anesthesia/no tourniquet approach has become increasingly popular. The authors evaluated the outcomes of awake open carpal tunnel release with and without a tourniquet. METHODS: The authors attempted to identify all relevant studies, regardless of language or publication status. A systematic database search for relevant studies was conducted in MEDLINE, EMBASE, EBSCO, and CENTRAL. Included studies compared patients undergoing awake open carpal tunnel release with and without an arm or forearm tourniquet. RESULTS: Eight studies evaluating 765 patients and 866 hands were included. Open carpal tunnel release with the wide awake, local anesthesia, no tourniquet approach resulted in a 2.14 point reduction on the visual analog scale (95% CI, 1.30 to 2.98; p < 0.001). The procedure was 1.82 minutes faster with the use of a tourniquet (95% CI, -3.26 to -0.39; p = 0.01). There were no significant differences between groups in intraoperative blood loss, surgeon perceived difficulty, and complications. CONCLUSION: This systematic review found that tourniquet use causes significantly more pain with no significant clinical benefit as compared with using a wide awake, no tourniquet approach in carpal tunnel decompression.


Assuntos
Síndrome do Túnel Carpal/cirurgia , Descompressão Cirúrgica/métodos , Nervo Mediano/cirurgia , Dor Pós-Operatória/diagnóstico , Torniquetes/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/instrumentação , Descompressão Cirúrgica/normas , Epinefrina , Humanos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Guias de Prática Clínica como Assunto , Torniquetes/normas , Resultado do Tratamento , Vasoconstritores/administração & dosagem , Vigília
16.
Ann Pharmacother ; 54(8): 804-814, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32054312

RESUMO

Objective: Commonly used drugs may be dangerous in case of extravasation. The lack of information from health care teams can lead to delays in both diagnosis and treatments. This review aims at alerting health care professionals about drugs and risk factors for extravasation and outlines recommendations for the diagnosis and treatment of extravasation. Data Source: A literature search of MEDLINE/PubMed, Scopus, the Cochrane Library, and Google Scholar was performed from 2000 to December 2019 using the following terms: extravasation, central venous line, peripheral venous line, irritant, and vesicant. Study Selection and Data Extraction: Overall, 140 articles dealing with drug extravasation were considered potentially relevant. Each article was critically appraised independently by 2 authors, leading to the inclusion of 80 relevant studies, guidelines, and reviews. Articles discussing incidents of extravasation in the neonatal and pediatric population of patients were excluded. Data Synthesis: Training of health care teams and writing care protocols are important for an optimal management of extravasations. A prompt consultation should be achieved by a specialist surgeon. The surgical procedure, if necessary, will consist of wound debridement followed by an abundant lavage. Relevance to Patient Care and Clinical Practice: This review discusses the management of drug extravasations according to their mechanism(s) of toxicity on tissues. It highlights the importance of a close monitoring of patients and the training of health care teams likely to face this type of adverse event. Conclusions: Extravasations still contribute to significant morbidity and mortality. A good knowledge of risk factors and the implementation of easily and quickly accessible standardized care protocols are 2 key elements in both prevention and treatment of extravasations.


Assuntos
Extravasamento de Materiais Terapêuticos e Diagnósticos , Vasoconstritores , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Extravasamento de Materiais Terapêuticos e Diagnósticos/terapia , Humanos , Concentração Osmolar , Fatores de Risco , Irrigação Terapêutica , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Vasoconstritores/química
17.
Crit Care Med ; 48(2): 225-229, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31939791

RESUMO

OBJECTIVES: To perform an updated systematic review and meta-analysis of clinical trials evaluating epinephrine for adult out-of-hospital cardiac arrest resuscitation. DATA SOURCES: The search included MEDLINE, EMBASE, and Ovid Evidence-Based Medicine, clinical trial registries, and bibliographies. STUDY SELECTION: Randomized and quasi-randomized controlled trials that compared the current standard dose of epinephrine to placebo, high or low dose epinephrine, any other vasopressor alone or in combination were screened by three independent reviewers. DATA EXTRACTION: Randomized and quasi-randomized controlled trials that compared the current standard dose of epinephrine to placebo, high or low dose epinephrine, any other vasopressor alone or in combination were screened by three independent reviewers. DATA SYNTHESIS: A total of 17 trials (21,510 patients) were included; seven were judged to be at high risk of bias. Compared to placebo, pooled results from two trials showed that standard dose of epinephrine increased return of spontaneous circulation (risk ratio, 3.09; 95% CI, 2.82-3.89), survival to hospital admission (risk ratio, 2.50; 95% CI, 1.68-3.72), and survival to discharge (risk ratio, 1.44; 95% CI, 1.11-1.86). The largest placebo-controlled trial showed that standard dose of epinephrine also improved survival at 30 days and 3 months but not neurologic outcomes, standard dose of epinephrine decreased return of spontaneous circulation (risk ratio, 0.87; 95% CI, 0.77-0.98) and survival to admission (risk ratio, 0.88; 95% CI, 0.78-0.99) when compared with high dose epinephrine. There were no differences in outcomes between standard dose of epinephrine and vasopressin alone or in combination with epinephrine. CONCLUSIONS: Largely based on one randomized controlled trial, standard dose of epinephrine improved overall survival but not neurologic outcomes in out-of-hospital cardiac arrest patients compared with placebo. There is a paucity of trials with meaningful patient outcomes; future epinephrine trials should evaluate dose and method of delivery on long-term survival, neurologic function, and quality of life after cardiac arrest.


Assuntos
Reanimação Cardiopulmonar/métodos , Epinefrina/uso terapêutico , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Parada Cardíaca Extra-Hospitalar/mortalidade , Vasoconstritores/uso terapêutico , Relação Dose-Resposta a Droga , Epinefrina/administração & dosagem , Humanos , Norepinefrina/uso terapêutico , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Vasoconstritores/administração & dosagem , Vasopressinas/uso terapêutico
18.
J Am Coll Cardiol ; 75(2): 194-204, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31948649

RESUMO

BACKGROUND: There is little evidence about pre-hospital advanced life support including epinephrine administration for pediatric out-of-hospital cardiac arrests (OHCAs). OBJECTIVES: This study aimed to assess the effect of pre-hospital epinephrine administration by emergency-medical-service (EMS) personnel for pediatric OHCA. METHODS: This nationwide population-based observational study in Japan enrolled pediatric patients age 8 to 17 years with OHCA between January 2007 and December 2016. Patients were sequentially matched with or without epinephrine during cardiac arrest using a risk-set matching based on time-dependent propensity score (probability of receiving epinephrine) calculated at each minute after initiation of cardiopulmonary resuscitation by EMS personnel. The primary endpoint was 1-month survival. Secondary endpoints were 1-month survival with favorable neurological outcome, defined as the cerebral performance category scale of 1 or 2, and pre-hospital return of spontaneous circulation (ROSC). RESULTS: During the study period, a total of 1,214,658 OHCA patients were registered, and 3,961 pediatric OHCAs were eligible for analyses. Of these, 306 (7.7%) patients received epinephrine and 3,655 (92.3%) did not receive epinephrine. After time-dependent propensity score-sequential matching, 608 patients were included in the matched cohort. In the matched cohort, there were no significant differences between the epinephrine and no epinephrine groups in 1-month survival (epinephrine: 10.2% [31 of 304] vs. no epinephrine: 7.9% [24 of 304]; risk ratio [RR]: 1.13 [95% confidence interval (CI): 0.67 to 1.93]) and favorable neurological outcome (epinephrine: 3.6% [11 of 304] vs. no epinephrine: 2.6% [8 of 304]; RR: 1.56 [95% CI: 0.61 to 3.96]), whereas the epinephrine group had a higher likelihood of achieving pre-hospital ROSC (epinephrine: 11.2% [34 of 304] vs. no epinephrine: 3.3% [10 of 304]; RR: 3.17 [95% CI: 1.54 to 6.54]). CONCLUSIONS: In this study, pre-hospital epinephrine administration was associated with ROSC, whereas there were no significant differences in 1-month survival and favorable neurological outcome between those with and without epinephrine.


Assuntos
Serviços Médicos de Emergência/métodos , Epinefrina/administração & dosagem , Parada Cardíaca Extra-Hospitalar/tratamento farmacológico , Parada Cardíaca Extra-Hospitalar/epidemiologia , Vasoconstritores/administração & dosagem , Adolescente , Criança , Feminino , Humanos , Japão/epidemiologia , Masculino , Parada Cardíaca Extra-Hospitalar/diagnóstico , Estudos Prospectivos , Sistema de Registros
19.
Rev Col Bras Cir ; 46(6): e20192269, 2020.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31967242

RESUMO

Conventionally, the association of local anesthetics with vasoconstrictors is avoided at extremities due to the risk of ischemia. However, recent studies suggest that there is safety in the use of vasoconstrictors at extremities. Thus, we sought to evaluate the effectiveness and safety of vasoconstrictor use combined with local anesthetics in digital nerve block compared to the use of anesthetics without vasoconstrictors, through a systematic review with meta-analysis of randomized clinical trials. Until May 2019 we searched MEDLINE, LILACS, SciELO, ScienceDirect, Scopus, ClinicalTrials.gov, and gray literature databases, without date or language restrictions. The keywords were the following: digital block, vasoconstrictor, and ischemia. We included randomized clinical trials in which there was the use of local anesthetics with associated or not with vasoconstrictors in digital blocks. In the primary variables, the occurrence of ischemic complications and the duration of anesthesia were analysed; in the secondary variables, the need for anesthetic reapplication, bleeding control, and latency were observed. Ten studies were included in this review. The occurrence of ischemia was not observed, regardless of the use of vasoconstrictors or not. The use of vasoconstrictors at a concentration of 1:100,000 or less was associated with longer anesthesia duration (P<0.00001), lower need for anesthetic reapplication (P=0.02), lower need for bleeding control (P=0.00006), and lower latency (P<0.00001). We could conclude that the use of vasoconstrictors associated with local anesthetics in digital block proved to be a safe and effective technique.


Assuntos
Anestésicos Locais/administração & dosagem , Bloqueio Nervoso/métodos , Vasoconstritores/administração & dosagem , Anestésicos Locais/efeitos adversos , Humanos , Bloqueio Nervoso/efeitos adversos , Vasoconstritores/efeitos adversos
20.
Ann Pharmacother ; 54(8): 742-749, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31928081

RESUMO

Background: Cortisol thresholds defining adrenal insufficiency (AI) in some cirrhosis-specific studies differ from those recommended by the SCCM/ESICM (Society of Critical Care Medicine/European Society of Intensive Care Medicine) guidelines, which may influence treatment decisions. Objective: To determine if stress-dose hydrocortisone (HC) improves outcomes in vasopressor-dependent patients meeting cirrhosis-specific criteria for AI. Methods: In this retrospective study, AI was defined using criteria from 2 studies in critically ill cirrhosis patients showing mortality reduction with HC (random cortisol <20 µg/dL, or if a standard-dose cosyntropin test was performed, baseline cortisol <15 µg/dL or delta cortisol <9 µg/dL if baseline = 15-34 µg/dL). Use of HC was at the discretion of the intensivist. The primary endpoint was days of vasopressor therapy. Secondary endpoints included hospital mortality and newly acquired infections. Sixty-four patients were evaluated; 40 patients received HC and 24 did not. Results: Mean random cortisol was significantly lower in the HC group (9.8 ± 3.2 vs 12.0 ± 3.7 µg/dL, P = 0.04). Delta cortisol also tended to be lower in the HC group (8.2 ± 4.4 vs 11.3 ± 6.4 µg/dL, P = 0.25). Patients in the HC group exhibited significantly fewer median days of vasopressor therapy (4.0 [2.0-7.0] vs 7.0 [4.2-10.8], P = 0.006), lower mortality (22.5% vs 50%, P = 0.02), and a similar incidence of newly acquired infections. Conclusion and Relevance: The use of HC in patients meeting cirrhosis-specific criteria for AI resulted in significantly shorter duration of vasopressor therapy, lower mortality, and no increased risk of infection. Use of traditional AI definitions may exclude patients with cirrhosis that could benefit from HC therapy.


Assuntos
Insuficiência Adrenal/tratamento farmacológico , Hidrocortisona/sangue , Cirrose Hepática/tratamento farmacológico , Norepinefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Insuficiência Adrenal/sangue , Insuficiência Adrenal/complicações , Insuficiência Adrenal/mortalidade , Adulto , Cuidados Críticos , Estado Terminal , Feminino , Humanos , Hidrocortisona/administração & dosagem , Incidência , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Estudos Retrospectivos , Fatores de Tempo , Vasoconstritores/administração & dosagem
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