Antonio Luis Eiras Falcão

Multiple organ failure in septic patients

Multiple organ failure (MOF) is the main cause of death in ICUs, especially affecting septic patients. It is strongly related to number of systems with failure, type of system involved, risk factors such as age, previous chronic diseases, delayed or inadequate resuscitation, persistent infection, immune suppression, and others. The prognoses is worse for patients rather than in elective or emergency surgical patients. The objective of this article is to provide data from our university teaching hospital ICU related to the incidence of septic patients, the distribution of MOF, and distribution of failure among each of the organs. The mortality rate, relationship between mortality and age, and mortality and types of organs affected were evaluated. The main bacterial causes of sepsis were also identified. A retrospective evaluation was done of 249 patients admitted to the ICU in a 4 month period during 1999. Fifty four patients had sepsis diagnosed by ACCS/SCCM criteria. There were 37 men and 17 women; 24 medical and 30 post-surgical patients (9 after elective surgery and 21 emergency patients). APACHE II score was calculated on admission and MOF, measured for the first five days, was diagnosed using Marshall and Meakins criteria. The statistical method used was non-parametric Mann-Whitney test, p<0.05 was considered significant. The incidence of sepsis was recorded in 54/249 patients (22%). Thirty of these 54 patients (56%) died. Death occurred in 2 of 11 patients with one organ failure (18%), in 14/27 with 2 or 3 organ failures (52%), and 14/16 with 4 or more organ failures (88%). None of the three patients 15 to 20 years old died, 17/32 (55%) patients age 21-60 years, and >61 years 13/19 (68%), died. There were 23 patients with positive bacterial culture. The most frequent bacteria found were: Pseudomonas aeruginosa (5), multiresistant Acinetobacter baumanii (3), Staphylococcus epidermidis (3), Enterobacter aerogenes (3), Klebsiella pneumoniae (2) and multiresistant Staphylococcus aureus (2). The mean value +/- SD of APACHE II (mortality risk) for survivors was 21 +/- 18 and for non-survivors 42 +/- 26 (p<0.001). We conclude that MOF due to sepsis in an ICU is frequent, with high mortality related to the number of failing organs, age and high APACHE II.

Edema pulmonar neurogênico: relato de dois casos

Neurogenic pulmonary edema is a rare and serious complication in patients with head injury. It also may develop after a variety of cerebral insults such as subarachnoid hemorrhage, brain tumors and after epileptic seizures. Thirty six patients with severe head injury and four patients with cerebrovascular insults treated in Intensive Care Unit of HC-UNICAMP from January to September 1995 were evaluated. In this period there were two patients with neurogenic pulmonary edema, one with head injury and other with intracerebral hemorrhage. Diagnosis was made by rapid onset of pulmonary edema, severe hypoxemia, decrease of pulmonary complacence and diffuse pulmonary infiltrations, without previous history of tracheal aspiration or any other risk factor for developement of adult respiratory distress syndrom. In the first case, with severe head trauma, neurogenic pulmonary edema was diagnosed at admission one hour after trauma, associated with severe systemic inflammatory reaction, and good outcome in three days. The second case, with hemorragic vascular insult, developed neurogenic pulmonary edema the fourth day after drenage of intracerebral hematom and died.

Fatores associados à maior mortalidade e tempo de internação prolongado em uma unidade de terapia intensiva de adultos.

OBJETIVO: A unidade de terapia intensiva e sinonimo de gravidade e apresenta taxa de mortalidade entre 5,4% e 33%. Com o aperfeicoamento de novas tecnologias, o paciente pode ser mantido por longo periodo nessa unidade, ocasionando altos custos financeiros, morais e psicologicos para todos os envolvidos. O objetivo do presente estudo foi avaliar os fatores associados a maior mortalidade e tempo de internacao prolongado em uma unidade de terapia intensiva adulto. METODOS: Participaram deste estudo todos os pacientes admitidos consecutivamente na unidade de terapia intensiva de adultos, clinica/cirurgica do Hospital das Clinicas da Universidade Estadual de Campinas, no periodo de seis meses. Foram coletados dados como: sexo, idade, diagnostico, antecedentes pessoais, APACHE II, dias de ventilacao mecânica invasiva, reintubacao orotraqueal, traqueostomia, dias de internacao na unidade de terapia intensiva, alta ou obito na unidade de terapia intensiva. RESULTADOS: Foram incluidos no estudo 401 pacientes, sendo 59,6% homens e 40,4% mulheres, com idade media de 53,8±18,0 anos. A media de internacao na unidade de terapia intensiva foi de 8,2±10,8 dias, com taxa de mortalidade de 13,46%. Dados significativos para mortalidade e tempo de internacao prolongado em unidade de terapia intensiva (p 11, traqueostomia e reintubacao. CONCLUSAO: APACHE >11, traqueostomia e reintubacao estiveram associados, neste estudo, a maior taxa de mortalidade e tempo de permanencia prolongado em unidade de terapia intensiva.

Syndromes related to sodium and arginine vasopressin alterations in post-operative neurosurgery

BACKGROUND Cerebral salt wasting syndrome (CSWS), syndrome of inappropriate antidiuretic hormone secretion (SIADH) and diabetes insipidus (DI) are frequently found in postoperative neurosurgery. PURPOSE To identify these syndromes following neurosurgery. METHOD The study included 30 patients who had been submitted to tumor resection and cerebral aneurysm clipping. Sodium levels in serum and urine and urine volume were measured daily up to the 5th day following surgery. Plasma arginine vasopressin (AVP) was measured on the first, third and fifth days post-surgery. RESULTS CSWS was found in 27/30 patients (90%), in 14 (46.7%) of whom it was associated with a reduction in the levels of plasma AVP (mix syndrome). SIADH was found in 3/30 patients (10%). There was no difference between the two groups of patients. CONCLUSION CSWS was the most common syndrome found, and in half the cases it was associated with DI. SIADH was the least frequent syndrome found.

Highlighting intracranial pressure monitoring in patients with severe acute brain trauma

Intracranial pressure (ICP) monitoring was carried out in 100 patients with severe acute brain trauma, primarily by means of a subarachnoid catheter. Statistical associations were evaluated between maximum ICP values and: 1) Glasgow Coma Scale (GCS) scores; 2) findings on computed tomography (CT) scans of the head; and 3) mortality. A significant association was found between low GCS scores (3 to 5) and high ICP levels, as well as between focal lesions on CT scans and elevated ICP. Mortality was significantly higher in patients with ICP > 40 mm Hg than in those with ICP < or = 20 mm Hg.

Influência da fisioterapia respiratória na pressão intracraniana em pacientes com traumatismo craniencefálico grave

OBJETIVO: Estudar a influencia das manobras de fisioterapia respiratoria na pressao intracraniana (PIC) dos pacientes com trauma craniencefalico grave. METODO: Trinta e cinco pacientes com trauma craniencefalico grave foram incluidos no estudo, sendo divididos em tres grupos: com PIC < 10, 11-20 e 21-30 mmHg. As variaveis monitorizadas foram: PIC e pressao arterial media. A pressao de perfusao cerebral foi calculada pela diferenca de pressao arterial media e PIC. RESULTADOS: A manobra de aspiracao traqueal causou aumento de PIC em todos os grupos. A pressao arterial media nao teve alteracoes e a pressao de perfusao cerebral diminuiu pouco, porem mantendo valores normais. CONCLUSAO: As manobras de fisioterapia respiratoria podem ser usadas com seguranca em pacientes com traumatismo craniencefalico grave, com PIC abaixo de 30 mmHg.Certo cuidado deve ser tomado durante a aspiracao traqueal.

Thrombolysis in massive pulmonary embolism based on the volumetric capnography

This is the first report of a patient submitted to chemical thrombolysis due to massive pulmonary embolism (PE) during the postoperative period of neurosurgery, in whom due to the lack of adequate clinical conditions, no imaging assessment was performed. Clinical, gasometric and capnographic data allowed the decision to perform the thrombolysis with safety. The P(a-et)CO2 gradient decreased from 46.4 mmHg to 11.8 mmHg (normal < 5 mmHg) and the end-tidal alveolar dead space fraction decreased from 0.85 to 0.37 (normal < 0.15) from the pre-thrombolysis period to the 7th day post-thrombolysis. We conclude that the volumetric capnography (VC) was useful in the patients diagnosis and clinical follow-up.This is the first report of a patient submitted to chemical thrombolysis due to massive pulmonary embolism (PE) during the postoperative period of neurosurgery, in whom due to the lack of adequate clinical conditions, no imaging assessment was performed. Clinical, gasometric and capnographic data allowed the decision to perform the thrombolysis with safety. The P(a-et)CO2 gradient decreased from 46.4 mmHg to 11.8 mmHg (normal < 5 mmHg) and the end-tidal alveolar dead space fraction decreased from 0.85 to 0.37 (normal < 0.15) from the pre-thrombolysis period to the 7th day post-thrombolysis. We conclude that the volumetric capnography (VC) was useful in the patients diagnosis and clinical follow-up.

Hemometabolismo cerebral : variações na fase aguda do coma traumatico

OBJECTIVE: to evaluate the interrelationships between cerebral and systemic hemometabolic alterations in patients with severe traumatic brain injury managed according to a standardized therapeutic protocol. DESIGN: prospective, interventional study in patients with traumatic coma. SETTING: a general Intensive Care Unit in a teaching hospital. PATIENTS AND METHODS: twenty-seven patients (21M e 6F), aging 14¾58 years, with severe acute brain trauma, presenting with three to eight points on the Glasgow Coma Scale, were prospectively evaluated according to a cumulative protocol for the management of acute intracranial hypertension, where intracranial pressure (ICP) and cerebral extraction of oxygen (CEO2) were routinely measured. Hemometabolic interrelationships involving mean arterial pressure (MAP), ICP, arterial carbon dioxide tension (PaCO2), CEO2, cerebral perfusion pressure (CPP) and systemic extraction of oxygen (SEO2) were analyzed. INTERVENTIONS: routine therapeutic procedures. RESULTS: no correlation was found between CEO2 and CPP (r = -0.07; p = 0.41). There was a significant negative correlation between PaCO2 and CEO2 (r = -0.24; p = 0.005) and a positive correlation between SEO2 and CEO2 (r = 0.24; p = 0.01). The mortality rate in this group of patients was 25.9% (7/27). Conclusion: 1) CPP and CEO2 are unrelated; 2) CEO2 and PaCO2 are closely related; 3) during optimized hyperventilation, CEO2 and SEO2 are coupled.

Volumetric capnography: in the diagnostic work-up of chronic thromboembolic disease.

The morbidity and mortality of pulmonary embolism (PE) have been found to be related to early diagnosis and appropriate treatment. The examinations used to diagnose PE are expensive and not always easily accessible. These options include noninvasive examinations, such as clinical pretests, ELISA D-dimer (DD) tests, and volumetric capnography (VCap). We report the case of a patient whose diagnosis of PE was made via pulmonary arteriography. The clinical pretest revealed a moderate probability of the patient having PE, and the DD result was negative; however, the VCap associated with arterial blood gases result was positive. The patient underwent all noninvasive exams following admission to hospital and again eight months after discharge. Results gained from invasive tests were similar to those produced by image exams, highlighting the importance of VCap as an important noninvasive tool.

FATORES QUE INFLUENCIARAM A EVOLUÇÃO DE 206 PACIENTES COM TRAUMATISMO CRANIENCEFÁLICO GRAVE

The search for head injury prognostic factors has been intense in the last decades. The importance of identification of these factors has been also recognised to treatment orientation and results estimatives. Based on 206 severe head injuried patients series, we analyzed the influence of factors over the outcome. The initial severity by Glasgow coma scale, the presence of intracranial hypertension (over 20 mmHg), the type of intracranial lesion and the presence of hypoxia, systemic hypotension or both, significantly influenced the results. The presence of multiple traumas (at least two sites of lesion over head injury), as age, did not influence the final results in this series.RESUMO -A busca de fatores prognosticos para o traumatismo craniencefalico (TCE) tem sido alvo de muitos estudos nas ultimasdecadas.A identificacao de indicadores consistentes da evolucao destes pacientes tem representado um grande desafio e sua utili dadeconsiderada evidente tanto para orientar o tratamento, quanto para a estimativa do resultado final. Baseados numa casuistica de206 pacientes com TCE grave (8 pontos ou menos pela Escala de Coma de Glasgow - ECG),estudamos a influencia de varios fatoressobre a evolucao dos pacientes.A gravidade inicial medida pela ECG, a presenca de hipertensao intracraniana (niveis acima de 20mmHg), o tipo de lesao intracraniana e a presenca de hipoxia, hipotensao arterial e a associacao de hipoxia e hipotensao arterialtiveram influencia significativa sobre a evolucao dos pacientes. A presenca de politraumatismo (pelo menos dois sitios de lesaoalem do TCE) e a idade (acima e abaixo de 40 anos) nao influenciaram significativamente a evolucao dos pacientes desta casuisti ca.PALAVRAS-CHAVE: traumatismo craniencefalico, pressao intracraniana, hipoxia, hipotensao arterial, politraumatismo, idade,prognostico.Relevant factors in 206 patients with severe head injuryABSTRACT - The search for head injury prognostic factors has been intense in the last decades.The importance of identification o fthese factors has been also recognised to treatment orientation and results estimatives.Based on 206 severe head injuried patie ntsseries,we analized the influence of factors over the outcome.The initial severity by Glasgow coma scale,the presence of intracr anialhypertension (over 20 mmHg),the type of intracranial lesion and the presence of hypoxia,systemic hypotension or both,significan tlyinfluenced the results.The presence of multiple traumas (at least two sites of lesion over head injury), as age, did not influenc e thefinal results in this series.KEY WORDS: head injury, intracranial pressure, hypoxia, hypotension, multiple trauma, age, outcome.