Carolina Kosour

Efeito imediato do ortostatismo em pacientes internados na unidade de terapia intensiva de adultos

Objetivo: Analisar o nivel de consciencia, efeitos pulmonares e hemodinâmicos em pacientes internados em UTI durante a posicao ortostatica. Metodos: Estudo realizado de abril de 2008 a julho de 2009 na unidade de terapia intensiva adulto do HCUNICAMP. Foram incluidos quinze pacientes que estiveram mecanicamente ventilados por mais de sete dias; traqueostomizados; em nebulizacao intermitente; pressao inspiratoria maxima inferior a -25cmH2O; indice de Tobin inferior a 105; drive ventilatorio preservado, ausencia de sedativos; pressao parcial de oxigenio arterial maior que 70mmHg; saturacao de oxigenio maior que 90% e estabilidade hemodinâmica. Os parâmetros avaliados, nas inclinacoes de 0°, 30° e 50°, foram o nivel de consciencia; reflexo de blinking; cirtometria toraco-abdominal; capacidade vital; volume corrente; volume minuto; forca da musculatura respiratoria e sinais vitais. Resultados: Nao houve alteracao do nivel de consciencia. A frequencia respiratoria e volume minuto reduziram-se em 30° com posterior aumento em 50°, no entanto, essas alteracoes nao foram estatisticamente significativas. A cirtometria abdominal e a pressao expiratoria maxima apresentaram aumento, novamente sem significância estatistica. Em relacao a pressao inspiratoria maxima e a capacidade vital observou-se aumento estatisticamente significante na comparacao entre as angulacoes 50o e 0°. Ja o volume corrente aumentou na comparacao entre as angulacoes 30o e 0o, e entre 50o e 0°. A pressao arterial media sofreu incremento somente na comparacao entre 50° e 0°. A frequencia cardiaca elevou-se na comparacao entre 30° e 0°, 50° e 0°, e 50° e 30°. Conclusao: O ortostatismo passivo proporcionou melhora do volume corrente, capacidade vital, pressao inspiratoria maxima, e aumento da frequencia cardiaca e pressao arterial media em pacientes criticos. Abstract

Utilização da ventilação não invasiva em edema agudo de pulmão e exacerbação da doença pulmonar obstrutiva crônica na emergência: preditores de insucesso

Objective: This study analyzed acute respiratory failure caused by acute pulmonary edema, as well as chronic obstructive pulmonary disease exacerbation, that was treated with non-invasive mechanical ventilation to identify the factors that are associated with the success or failure non-invasive mechanical ventilation in urgent and emergency service. Methods: This study was a prospective, descriptive and analytical study. We included patients of both genders aged ≥18 years who used non- invasive mechanical ventilation due to acute respiratory failure that was secondary to acute pulmonary edema or chronic obstructive pulmonary disease exacerbation. Patients with acute respiratory failure that was secondary to pathologies other than acute pulmonary edema and chronic obstructive pulmonary disease or who presented with contraindications for the technique were excluded. Expiratory pressures between 5 and 8 cmH 2 O and inspiratory pressures between 10 and 12 cmH 2 O were used. Supplemental oxygen maintained peripheral oxygen saturation at >90%. The primary outcome was endotracheal intubation. Results: A total of 152 patients were included. The median non-invasive mechanical ventilation time was 6 hours (range 1 - 32 hours) for chronic obstructive pulmonary disease patients (n=60) and 5 hours (range 2 - 32 hours) for acute pulmonary edema patients (n=92). Most (75.7%) patients progressed successfully. However, reduced APACHE II scores and lower peripheral oxygen saturation were observed. These results were statistically significant in patients who progressed to intubation (p 25 rpm, higher APACHE II scores, BiPAP use and chronic obstructive pulmonary disease diagnosis were associated with endotracheal intubation. Higher GCS and SpO 2 values were associated with NIV success. Non- invasive mechanical ventilation can be used in emergency services in acute respiratory failure cases caused by acute pulmonary edema and chronic obstructive pulmonary disease exacerbation, but patients with variables related to a higher percentage of endotracheal intubation should be specially monitored.

Glasgow outcome scale at hospital discharge as a prognostic index in patients with severe traumatic brain injury

OBJECTIVE Evaluate the Glasgow outcome scale (GOS) at discharge (GOS-HD) as a prognostic indicator in patients with traumatic brain injury (TBI). METHOD Retrospective data were collected of 45 patients, with Glasgow coma scale <8, age 25±10 years, 36 men, from medical records. Later, at home visit, two measures were scored: GOS-HD (according to information from family members) and GOS LATE (12 months after TBI). RESULTS At discharge, the ERG showed: vegetative state (VS) in 2 (4%), severe disability (SD) in 27 (60%), moderate disability (MD) in 15 (33%) and good recovery (GR) in 1 (2%). After 12 months: death in 5 (11%), VS in 1 (2%), SD in 7 (16%), MD in 9 (20%) and GR in 23 (51%). Variables associated with poor outcome were: worse GOS-HD (p=0.03), neurosurgical procedures (p=0.008) and the kind of brain injury (p=0.009). CONCLUSION The GOS-HD was indicator of prognosis in patients with severe TBI.

Influência do nível de ruídos na percepção do estresse em pacientes cardíacos

OBJECTIVES: To identify the main causes of stress in patients staying in a coronary unit and to assess the influence of noise levels on their perception of stress. METHODS: This was a prospective, descriptive and quantitative study conducted between June and November 2009 in the Coronary Unit of the Hospital de Clinicas da Universidade Estadual de Campinas. The Intensive Care Unit Environmental Stressor Scale was used on the first, second and third days of hospitalization to identify stressors. The noise level was measured on the first and second nights using an Instrutherm DEC-460 decibel meter. RESULTS: Overall, 32 clinical heart disease patients were included. The median Intensive Care Unit Environmental Stressor Scale scores were 67.5, 60.5 and 59.5 for the first, second and third days, respectively. The differences were not statistically significant. The highest noise level (a median of 58.7 dB) was detected on the second night at 9:00 pm; the lowest level (51.5 dB) was measured on the first night at 12:00 am. In a multiple linear regression model, the first-night noise level had a 33% correlation with the second-day stress scale score, and for the second night, the correlation with the third-day stress scale score was 32.8% (p = 0.001). CONCLUSION: Patients admitted into a coronary unit have an increased perception of stress. Higher noise levels are also responsible for the perception of stress in these patients.

Percepção dos familiares de pacientes internados em Unidade de Terapia Intensiva em relação à atuação da Fisioterapia e à identificação de suas necessidades

Trata-se de um estudo descritivo e de abordagem qualitativa, que teve como objetivo verificar o conhecimento dos familiares de pacientes internados na Unidade de Terapia Intensiva do Hospital de Clinicas da Universidade Estadual de Campinas com relacao a atuacao da Fisioterapia intensiva neste servico, bem como identificar suas necessidades. Foram entrevistados 60 familiares, sendo estes questionados a respeito do servico de Fisioterapia e submetidos ao Inventario de Necessidades e Estressores de Familiares em Terapia Intensiva. Foi observado que a maioria deles desconhecia a atuacao da Fisioterapia em tal Unidade, porem os que conheciam atribuiram nota maxima ao servico. Em relacao as necessidades dos familiares, notou-se que 56,7% julgaram necessario saber fatos concretos a respeito do progresso de seu familiar; 60% gostariam de ter a certeza que seu familiar esta recebendo o melhor tratamento e 71,7% gostariam de ter dias e horarios de visitas mais flexiveis. Constatou-se a falta de informacoes dos entrevistados em relacao a atuacao da Fisioterapia na Unidade de Terapia Intensiva. Foram identificadas as necessidades dos familiares, sendo possivel, com isto, executar acoes de melhoria. Por meio do presente estudo, a Unidade de Terapia Intensiva do Hospital de Clinicas da Universidade Estadual de Campinas identificou as principais necessidades dos familiares, adequou o espaco fisico, implementou salas de acolhimento familiar e o curso de especializacao em Fisioterapia Respiratoria em Unidade de Terapia Intensiva Adulto, e criou informativos visuais quanto a sua atuacao para melhores acolhimento e compreensao dos familiares.

Fator natriurético atrial: ele é o responsável pela hiponatremia e natriurese em neurocirurgia?

Objective: To evaluate the presence of hyponatremia and natriuresis and their association with atrial natriuretic factor in neurosurgery patients. Methods: The study included 30 patients who had been submitted to intracranial tumor resection and cerebral aneurism clipping. Both plasma and urinary sodium and plasma atrial natriuretic factor were measured during the preoperative and postoperative time periods. Results: Hyponatremia was present in 63.33% of the patients, particularly on the first postoperative day. Natriuresis was present in 93.33% of the patients, particularly on the second postoperative day. Plasma atrial natriuretic factor was increased in 92.60% of the patients in at least one of the postoperative days; however, there was no statistically significant association between the atrial natriuretic factor and plasma sodium and between the atrial natriuretic factor and urinary sodium. Conclusion: Hyponatremia and natriuresis were present in most patients after neurosurgery; however, the atrial natriuretic factor cannot be considered to be directly responsible for these alterations in neurosurgery patients. Other natriuretic factors are likely to be involved.Objective To evaluate the presence of hyponatremia and natriuresis and their association with atrial natriuretic factor in neurosurgery patients. Methods The study included 30 patients who had been submitted to intracranial tumor resection and cerebral aneurism clipping. Both plasma and urinary sodium and plasma atrial natriuretic factor were measured during the preoperative and postoperative time periods. Results Hyponatremia was present in 63.33% of the patients, particularly on the first postoperative day. Natriuresis was present in 93.33% of the patients, particularly on the second postoperative day. Plasma atrial natriuretic factor was increased in 92.60% of the patients in at least one of the postoperative days; however, there was no statistically significant association between the atrial natriuretic factor and plasma sodium and between the atrial natriuretic factor and urinary sodium. Conclusion Hyponatremia and natriuresis were present in most patients after neurosurgery; however, the atrial natriuretic factor cannot be considered to be directly responsible for these alterations in neurosurgery patients. Other natriuretic factors are likely to be involved.

Realidade virtual na função motora de membros inferiores pós-acidente vascular encefálico

Strokes can generate significant motor, tonic and sensitive changes. Virtual reality (RV), focused on rehabilitation, can bring several benefits such as improvements on physical fitness, motor skills and balance. Objective: To assess the effects of the RV intervention to the static and dynamic balance, weight load on the affected limb, tone and muscle recruitment, functional independence and sensorimotor function in post-stroke individuals. Methods: Quasi-experimental and prospective clinical study with 6 subjects with diagnosis of stroke. Before and after the intervention with Nintendo Wii Fit Plus, the subjects were assessed by the Berg Balance Scale, Timed “Up and Go” and Dynamic Floor Index; Gait Test (GT); Modified Ashworth Scale (MAS); Electromyography; Barthel Index and Fugl-Meyer Scale (FMS). The Statistical analysis used Kolmogorov-Smirnov test, t test and Wilcoxon. Results: The 1st and 15th session evaluations have shown that GT (p = 0.03, d = 1.96, P = 96%), MAS for hip extensor muscles (p = 0.04; d = 3.77; P = 99%), knee extensors (p = 0.04; d = 3.23; P = 99%), plantar flexors (p = 0.01; d = 3.18; P = 99%), FMS in coordination/velocity dimensions (p = 0.02; d = 6.74; P = 100%) and sensitivity (p = 0.01) presented significant results, large effect size and power above 90%. Significant values were not found to the other evaluations. Conclusion: The RV rehabilitation program was effective and improved the weight-load in affected limb, muscle tone and sensorimotor function of the subjects

Comparison between two physiotherapy protocols for patients with chronic kidney disease on dialysis

[Purpose] To compare the effects of two physiotherapy protocols for chronic kidney disease patients on dialysis. [Subjects and Methods] This is a prospective, randomized study, in chronic kidney disease patients 18 years of age or older on dialysis. Sessions for each group (were conducted three times per week for a total of 10 sessions), during hemodialysis. Respiratory muscle strength (maximal inspiratory and expiratory pressure), peak expiratory flow, and peripheral muscle strength were evaluated. The study group received motor and respiratory physiotherapy, and the control group received motor physiotherapy alone. [Results] We observed a significant increase in the maximal inspiratory pressure in the study group in the 5th and 10th sessions and in the maximal expiratory pressure in the 1st session, peak flow in the 1st and 10th sessions, and dynamometry in the 10th session. In the control group, there was a significant decrease in maximal inspiratory pressure in the 5th and 10th sessions, and in maximal expiratory pressure in the 10th session, peak flow in the 5th and 10th sessions, and dynamometry in the 5th session. [Conclusion] Implementation of motor physiotherapy combined with respiratory physiotherapy may have contributed to the improvement of the variables analyzed in the study group.

Effect of Ultrafiltration on Pulmonary Function and Interleukins in Patients Undergoing Cardiopulmonary Bypass

OBJECTIVE To evaluate the effect of ultrafiltration on interleukins, TNF-α levels, and pulmonary function in patients undergoing coronary artery bypass grafting (CABG). DESIGN Prospective, randomized, controlled trial. SETTING University hospital. PARTICIPANTS Forty patients undergoing CABG were randomized into a group assigned to receive ultrafiltration (UF) during cardiopulmonary bypass (CPB) or into another group (control) that underwent the same procedure but without ultrafiltration. METHODS Interleukins and TNF-α levels, pulmonary gas exchange, and ventilatory mechanics were measured in the preoperative, intraoperative, and postoperative periods. Interleukins and TNF-α also were analyzed in the perfusate of the test group. MEASUREMENTS AND MAIN RESULTS There were increases in IL-6 and IL-8 at 30 minutes after CPB and 6, 12, 24, and 36 hours after surgery, along with an increase in TNF-α at 30 minutes after CPB and 24, 36, and 48 hours after surgery in both groups. IL-1 increased at 30 minutes after CPB and 12 hours after surgery, while IL-6 increased 24 and 36 hours after surgery in the UF group. The analysis of the ultrafiltrate showed the presence of TNF-α and traces of IL-1β, IL-6, and IL-8. There were alterations in the oxygen index, alveolar-arterial oxygen difference, deadspace, pulmonary static compliance and airway resistance after anesthesia and sternotomy, as well as in airway resistance at 6 hours after surgery in both groups, with no difference between them. CONCLUSIONS Ultrafiltration increased the serum level of IL-1 and IL-6, while it did not interfere with gas exchange and pulmonary mechanics in CABG.