Assessment of the prescription of red blood cell concentrates in the pediatric age group / Avaliação da prescrição de concentrados de hemácias na faixa etária pediátrica

Summary Objective: To verify the adequacy of red blood cell (RBC) prescription to pediatric patients in different sectors of a pediatric hospital. Method: A retrospective study was conducted including 837/990 RBC transfusion requisition forms for children and adolescents (0 to 13 years old) filed in between January 2007 and April 2015 by the pediatricians of the emergency room (ER), infirmary ward and intensive care unit (pICU). Transfusion requisition forms belonging to patients with chronic anemia or acute hemorrhage, as well as incompletes requisition forms, were excluded. Results: Trigger, prescribed volume and subtype of RBC concentrates were adequate in 532 (65.3%), 460 (58.8%) and 805 (96.2%) of the transfusions, respectively. When the clinical picture was considered, prescription adequacy was higher compared to the use of the hemoglobin level alone (70.9% vs. 41%). The pICU had the highest correct trigger percentage (343 [71.6%]; p<0.001) while the ER showed more often adequate prescribed volumes (119 [66.1%]; p=0.020). The most common inadequacy regarding volume was that of prescriptions above the recommendation > 15 mL/kg found in 309 cases (36.9%). Thirty-two (32) RBC subtypes were requested and none were consistent with current recommendations. Conclusion: The results obtained in our study showed that RBC transfusion occurred more appropriately when the clinical picture was taken into account at request. There was a tendency to prescribe higher volumes and RBC subtypes without the justification of current protocols. Hemotherapic teachings at undergraduate level and medical residency must be improved.

Resumo Objetivo: Verificar a adequação na prescrição de concentrado de hemácias (CH) por pediatras em diferentes setores de um hospital pediátrico. Método: Realizou-se estudo retrospectivo onde avaliamos 837/990 fichas de requisição de CH para crianças e adolescentes (0 a 13 anos), preenchidas entre janeiro de 2007 e abril de 2015 pelos médicos pediatras do pronto-socorro (PS), da enfermaria e da unidade de terapia intensiva (UTI). Excluíram-se as transfusões realizadas em portadores de anemia crônica, crianças com hemorragia aguda e requisições incompletas. Resultados: Gatilho, volume prescrito e subtipo de concentrado de hemácias foram adequados em 532 (65,3%), 460 (58,8%) e 805 (96,2%) das transfusões, respectivamente. Quando foi considerado o quadro clínico, a adequação foi maior em comparação à prescrição pelo valor isolado da hemoglobina (70,9% vs. 41%). A UTI teve o maior percentual de acerto no gatilho (343 [71,6%]; p<0,001) e o PS, no volume prescrito (119 [66,1%]; p=0,020). A inadequação mais comum, em relação ao volume, foi a prescrição acima da recomendação (> 15 mL/kg, 309 [36,9%]). Foram solicitados 32 subtipos de CH e nenhum estava de acordo com as indicações atuais. Conclusão: Os resultados obtidos mostram que a transfusão de CH aconteceu de forma mais adequada quando a situação clínica era levada em conta na solicitação. Houve uma tendência à prescrição de volumes elevados e de subtipos de hemácias não justificados segundo os protocolos atuais. É necessário melhorar o ensino de hemoterapia na graduação e residência médica.

Dehydration, hemodynamics and fluid volume optimization after induction of general anesthesia

OBJECTIVES: Fluid volume optimization guided by stroke volume measurements reduces complications of colorectal and high-risk surgeries. We studied whether dehydration or a strong hemodynamic response to general anesthesia increases the probability of fluid responsiveness before surgery begins. METHODS: Cardiac output, stroke volume, central venous pressure and arterial pressures were measured in 111 patients before general anesthesia (baseline), after induction and stepwise after three bolus infusions of 3 ml/kg of 6% hydroxyethyl starch 130/0.4 (n = 86) or Ringer's lactate (n = 25). A subgroup of 30 patients who received starch were preloaded with 500 ml of Ringer's lactate. Blood volume changes were estimated from the hemoglobin concentration and dehydration was estimated from evidence of renal water conservation in urine samples. RESULTS: Induction of anesthesia decreased the stroke volume to 62% of baseline (mean); administration of fluids restored this value to 84% (starch) and 68% (Ringer's). The optimized stroke volume index was clustered around 35-40 ml/m2/beat. Additional fluid boluses increased the stroke volume by ≥10% (a sign of fluid responsiveness) in patients with dehydration, as suggested by a low cardiac index and central venous pressure at baseline and by high urinary osmolality, creatinine concentration and ...

Alta utilidad de monitorización hemodinámica con ecocardiografía transesofágica intraoperatoria en cirugía ortopédica / Intraoperative hemodynamic monitoring using transesophageal echocardiography in orthopedic surgery

Background: Orthopedic surgery is commonly performed in elderly patients with higher cardiovascular surgical risk. Hemodynamic monitoring in these patients may prevent perioperative complications. Aim: To assess the usefulness of transesophageal echocargiography (TEE) for intraoperative cardiovascular monitoring during orthopedic surgery. Material and methods: Patients older than 65 years subjected to orthopedic surgery using general anesthesia and with a high cardiovascular risk were studied. Intraoperative TEE was performed to assess intravascular volume, myocardial contractility and the presence of myocardial ischemia. Results: Fifty three patients aged 72±5 years were studied. Hemodynamic stability was detected in 68 percent of patients, mainly reflected as episodes of hypovolemia. Myocardial ischemia was detected in two patients and embolic episodes in six (11 percent). Conclusions: Intraoperative TEE was useful for the hemodynamic evaluation of patients with high cardiovascular risk.

La mujer embarazada agredida por trauma y su atención prehospitalaria / La pregnant woman who undergoes trauma: pre-hospital care and medical attention

El trauma en el embarazo se ha incrementado en los últimos años llegando hasta un 7 por ciento. Se le ha asociado con un alto riesgo de pérdida del feto. La causa principal son los accidentes automovilísticos y el tipo más frecuente es el trauma cerrado. Para una adecuada atención prehospitalaria es necesario considerar sus cambios fisiológicos tales como la presión arterial, el pulso, el volumen sanguíneo, los cambios de posición del útero, vejiga, corazón, etc. Los efectos del trauma se pueden presentar entre otros como shock, abruptio placenta, ruptura uterina, lesiones fetales directas y hemorragia maternofetal. El abordaje debe ser conducido con la misma agresividad que para una paciente no embarazada, tomando en cuenta sus cambios fisiológicos y como primera prioridad la reanimación materna. Toda vez que los signos aparentemente estables de la madre pueden no ser indicativo real, el transporte rápido al centro de trauma es esencial