Biochemical and Physiological Events Involved in Responses to the Ultrasound Used in Physiotherapy: A Review.

Therapeutic ultrasound (TUS) is the ultrasound modality widely used in physical therapy for the treatment of acute and chronic injuries of various biological tissues. Its thermal and mechanical effects modify the permeability of the plasma membrane, the flow of ions and molecules and cell signaling and, in this way, promote the cascade of physiological events that culminate in the repair of injuries. This article is a review of the biochemical and physiological effects of TUS with parameters commonly used by physical therapists. Integrins can translate the mechanical signal of the TUS into a cellular biochemical signal for protein synthesis and modification of the active site of enzymes, so cell function and metabolism are modified. TUS also alters the permeability of the plasma membrane, allowing the influx of ions and molecules that modulate the cellular electrochemical signaling pathways. With biochemical and electrochemical signals tampered with, the cellular response to damage is then modified or enhanced. Greater release of pro-inflammatory factors, cytokines and growth factors, increased blood flow and activation of protein kinases also seem to be involved in the therapeutic response of TUS. Although a vast number of publications describe the mechanisms by which TUS can interact with the biological system, little is known about the metabolic possibilities of TUS because of the lack of standardization in its application.

Impact of fast-track management on adult cardiac surgery: clinical and hospital outcomes. / Impacto do fast track em cirurgia cardíaca de adultos: desfechos clínicos e hospitalares.

OBJECTIVE: To compare the impact of two fast-track strategies regarding the extubation time and removal of invasive mechanical ventilation in adults after cardiac surgery on clinical and hospital outcomes. METHODS: This was a retrospective cohort study with patients undergoing cardiac surgery. Patients were classified according to the extubation time as the Control Group (extubated 6 hours after admission to the intensive care unit, with a maximum mechanical ventilation time of 18 hours), Group 1 (extubated in the operating room after surgery) and Group 2 (extubated within 6 hours after admission to the intensive care unit). The primary outcomes analyzed were vital capacity on the first postoperative day, length of hospital stay, and length of stay in the intensive care unit. The secondary outcomes were reintubation, hospital-acquired pneumonia, sepsis, and death. RESULTS: For the 223 patients evaluated, the vital capacity was lower in Groups 1 and 2 compared to the Control (p = 0.000 and p = 0.046, respectively). The length of stay in the intensive care unit was significantly lower in Groups 1 and 2 compared to the Control (p = 0.009 and p = 0.000, respectively), whereas the length of hospital stay was lower in Group 1 compared to the Control (p = 0.014). There was an association between extubation in the operating room (Group 1) with reintubation (p = 0.025) and postoperative complications (p = 0.038). CONCLUSION: Patients undergoing fast-track management with extubation within 6 hours had shorter stays in the intensive care unit without increasing postoperative complications and death. Patients extubated in the operating room had a shorter hospital stay and a shorter stay in the intensive care unit but showed an increase in the frequency of reintubation and postoperative complications.

OBJETIVO: Comparar o impacto de duas estratégias de fast track quanto ao momento de extubação e retirada da ventilação mecânica invasiva de adultos no pós-operatório cardíaco em desfechos clínicos e hospitalares. MÉTODOS: Estudo de coorte retrospectivo com pacientes submetidos à cirurgia cardíaca. Os pacientes foram classificados de acordo com o tempo de extubação em Grupo Controle (extubados após 6 horas de admissão na unidade de terapia intensiva, com tempo máximo de ventilação mecânica de 18 horas), Grupo 1 (extubados em sala de operação após término da cirurgia) e Grupo 2 (extubados em até 6 horas pós-admissão na unidade de terapia intensiva). Os desfechos primários analisados foram: capacidade vital no primeiro dia de pós-operatório, tempo de internamento hospitalar e na unidade de terapia intensiva. Os desfechos secundários foram reintubação, pneumonia adquirida no hospital, sepse e óbito. RESULTADOS: Para os 223 pacientes avaliados, a capacidade vital foi menor nos Grupos 1 e 2 comparados ao Controle (p = 0,000 e p = 0,046, respectivamente). Os dias de internamento em unidade de terapia intensiva foram significativamente menores nos Grupos 1 e 2 quando comparados ao Controle (p = 0,009 e p = 0,000, respectivamente), já os dias de internamento hospitalar foram menores no Grupo 1 quando comparado ao Controle (p = 0,014). Houve associação entre a extubação na sala de operação (Grupo 1) com reintubação (p = 0,025) e complicações pós-cirúrgicas (p=0,038). CONCLUSÃO: Pacientes submetidos ao fast track com extubação em até 6 horas apresentaram menor tempo de internamento em unidade de terapia intensiva sem aumentar complicações pós-cirúrgicas e óbito. Pacientes extubados em sala de operação tiveram menor tempo de internamento hospitalar e em unidade de terapia intensiva, mas apresentaram aumento na frequência de reintubação e complicações pós-cirúrgicas.

Impacto do fast track em cirurgia cardíaca de adultos: desfechos clínicos e hospitalares / Impact of fast-track management on adult cardiac surgery: clinical and hospital outcomes

RESUMO Objetivo: Comparar o impacto de duas estratégias de fast track quanto ao momento de extubação e retirada da ventilação mecânica invasiva de adultos no pós-operatório cardíaco em desfechos clínicos e hospitalares. Métodos: Estudo de coorte retrospectivo com pacientes submetidos à cirurgia cardíaca. Os pacientes foram classificados de acordo com o tempo de extubação em Grupo Controle (extubados após 6 horas de admissão na unidade de terapia intensiva, com tempo máximo de ventilação mecânica de 18 horas), Grupo 1 (extubados em sala de operação após término da cirurgia) e Grupo 2 (extubados em até 6 horas pós-admissão na unidade de terapia intensiva). Os desfechos primários analisados foram: capacidade vital no primeiro dia de pós-operatório, tempo de internamento hospitalar e na unidade de terapia intensiva. Os desfechos secundários foram reintubação, pneumonia adquirida no hospital, sepse e óbito. Resultados: Para os 223 pacientes avaliados, a capacidade vital foi menor nos Grupos 1 e 2 comparados ao Controle (p = 0,000 e p = 0,046, respectivamente). Os dias de internamento em unidade de terapia intensiva foram significativamente menores nos Grupos 1 e 2 quando comparados ao Controle (p = 0,009 e p = 0,000, respectivamente), já os dias de internamento hospitalar foram menores no Grupo 1 quando comparado ao Controle (p = 0,014). Houve associação entre a extubação na sala de operação (Grupo 1) com reintubação (p = 0,025) e complicações pós-cirúrgicas (p=0,038). Conclusão: Pacientes submetidos ao fast track com extubação em até 6 horas apresentaram menor tempo de internamento em unidade de terapia intensiva sem aumentar complicações pós-cirúrgicas e óbito. Pacientes extubados em sala de operação tiveram menor tempo de internamento hospitalar e em unidade de terapia intensiva, mas apresentaram aumento na frequência de reintubação e complicações pós-cirúrgicas.

ABSTRACT Objective: To compare the impact of two fast-track strategies regarding the extubation time and removal of invasive mechanical ventilation in adults after cardiac surgery on clinical and hospital outcomes. Methods: This was a retrospective cohort study with patients undergoing cardiac surgery. Patients were classified according to the extubation time as the Control Group (extubated 6 hours after admission to the intensive care unit, with a maximum mechanical ventilation time of 18 hours), Group 1 (extubated in the operating room after surgery) and Group 2 (extubated within 6 hours after admission to the intensive care unit). The primary outcomes analyzed were vital capacity on the first postoperative day, length of hospital stay, and length of stay in the intensive care unit. The secondary outcomes were reintubation, hospital-acquired pneumonia, sepsis, and death. Results: For the 223 patients evaluated, the vital capacity was lower in Groups 1 and 2 compared to the Control (p = 0.000 and p = 0.046, respectively). The length of stay in the intensive care unit was significantly lower in Groups 1 and 2 compared to the Control (p = 0.009 and p = 0.000, respectively), whereas the length of hospital stay was lower in Group 1 compared to the Control (p = 0.014). There was an association between extubation in the operating room (Group 1) with reintubation (p = 0.025) and postoperative complications (p = 0.038). Conclusion: Patients undergoing fast-track management with extubation within 6 hours had shorter stays in the intensive care unit without increasing postoperative complications and death. Patients extubated in the operating room had a shorter hospital stay and a shorter stay in the intensive care unit but showed an increase in the frequency of reintubation and postoperative complications.

The impact of positive end-expiratory pressure on cerebral perfusion pressure in adult patients with hemorrhagic stroke. / Repercussão da pressão positiva expiratória final na pressão de perfusão cerebral em pacientes adultos com acidente vascular hemorrágico.

UNLABELLED: Positive intrathoracic pressure may cause hemodynamic changes, which can be transmitted to the cranial compartment, changing intracranial pressure and cerebral perfusion pressure. This can be increased when high positive end-expiratory pressure values are used. OBJECTIVE: To measure the impact of different positive end-expiratory pressure levels on intracranial pressure, cerebral perfusion pressure and mean blood pressure. METHOD: This study was conducted in a neurological intensive care unit and included 25 adult hemorrhagic stroke patients who were mechanically ventilated on airway pressure control mode. Patients were subjected to various positive end-expiratory values ranging between 0 and 14 cmH2O. The order of these values were randomized, and the variables were assessed five minutes after each new positive end-expiratory pressure level was initiated. RESULTS: Incremental positive end-expiratory pressures led to increased intracranial pressure (p < 0.001), however, no statistically significant changes were observed in mean blood pressure or cerebral perfusion pressure. CONCLUSION: In this population of patients with hemorrhagic stroke, positive end-expiratory pressure values up to 14 cmH2O did not alter cerebral perfusion pressure or mean blood pressure. Increased intracranial pressures were noted, although these elevations were not clinically significant.

Repercussão da pressão positiva expiratória final na pressão de perfusão cerebral em pacientes adultos com acidente vascular hemorrágico / The impact of positive end-expiratory pressure on cerebral perfusion pressure in adult patients with hemorrhagic stroke

A pressão positiva intratorácica pode levar a alterações hemodinâmicas com repercussão no compartimento intracraniano, alterando a pressão intracraniana e a pressão de perfusão cerebral. Esse efeito pode se tornar mais intenso quando utilizados elevados valores de pressão positiva expiratória final. OBJETIVO: Medir o impacto que diferentes valores de pressão positiva expiratória final causam na pressão intracraniana, na pressão de perfusão cerebral e pressão arterial média. MÉTODO: O estudo foi desenvolvido em uma unidade de terapia intensiva neurológica envolvendo 25 pacientes adultos com acidente vascular cerebral hemorrágico, ventilados mecanicamente no modo com controle pressórico de vias aéreas. Foram instituídos valores de pressão positiva expiratória final variando de 0 a 14 cmH2O, de forma aleatória através de sorteio, utilizando valores pares. A monitorização das variáveis estudadas ocorreu após cinco minutos em cada patamar de pressão positiva expiratória final. RESULTADOS: O incremento da pressão positiva expiratória final aumentou a pressão intracraniana, (p < 0,001) sem causar alteração estatisticamente significativa na pressão arterial média ou na pressão de perfusão cerebral. CONCLUSÃO: Na população estudada, de pacientes com acidente vascular cerebral hemorrágico, os achados mostraram que valores de pressão positiva expiratória final até 14 cmH2O, não alteram a pressão de perfusão cerebral e a pressão arterial média, aumentando a pressão intracraniana, porém sem relevância clínica.

Positive intrathoracic pressure may cause hemodynamic changes, which can be transmitted to the cranial compartment, changing intracranial pressure and cerebral perfusion pressure. This can be increased when high positive end-expiratory pressure values are used. OBJECTIVE: To measure the impact of different positive end-expiratory pressure levels on intracranial pressure, cerebral perfusion pressure and mean blood pressure. METHOD: This study was conducted in a neurological intensive care unit and included 25 adult hemorrhagic stroke patients who were mechanically ventilated on airway pressure control mode. Patients were subjected to various positive end-expiratory values ranging between 0 and 14 cmH2O. The order of these values were randomized, and the variables were assessed five minutes after each new positive end-expiratory pressure level was initiated. RESULTS: Incremental positive end-expiratory pressures led to increased intracranial pressure (p < 0.001), however, no statistically significant changes were observed in mean blood pressure or cerebral perfusion pressure. CONCLUSION: In this population of patients with hemorrhagic stroke, positive end-expiratory pressure values up to 14 cmH2O did not alter cerebral perfusion pressure or mean blood pressure. Increased intracranial pressures were noted, although these elevations were not clinically significant.