Desanka Dragosavac

Recomendações brasileiras de ventilação mecânica 2013. Parte I

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associacao de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in Sao Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Postoperative muscle training improves tidal volume and vital capacity in the postoperative period of CABG surgery

OBJECTIVE To evaluate lung function and respiratory muscle strength in the postoperative period and investigate the effect of inspiratory muscle training on measures of respiratory muscle performance in patients undergoing coronary artery bypass grafting. METHODS A randomized study with 47 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. They were divided into study group (SG) 23 patients and control group (CG) 24 patients, mean age 61.83 ± 8.61 and 66.33 ± 10.20 years, EuroSCORE SG 0.71 ± 0.0018 and CG 0.76 ± 0.0029, respectively. The study group underwent physical therapy and inspiratory muscle training with threshold IMT® and CG underwent conventional physiotherapy. We compared the maximal respiratory pressures (MIP and MEP), tidal volume (TV), vital capacity (VC) and peak expiratory flow (peak flow) preoperatively (Pre-OP), 1st (PO1) and 3rd (PO3) postoperative day. RESULTS There was a significant reduction in all variables measured on PO1 compared to preoperative values in both groups, MIP (P <0.0001), MEP (P <0.0001), TV SG (P <0.0004) and CG (P <0.0001) and VC SG (P <0.0001) and CG (P <0.0001) and peak flow (P <0.0001). At PO3, SG presented higher value of VC, GE 1230.4 ± 477.86 ml vs. GC 919.17 ± 394.47 ml (P=0.0222) and TV SG 608.09 ± 178.24 ml vs. CG 506.96 ± 168.31 ml (P= 0.0490). CONCLUSION Patients undergoing cardiac surgery experience reduced ventilatory capacity and respiratory muscle strength after surgery. Muscle training was performed to retrieve TV and VC in the PO3, in the trained group.OBJETIVO: Avaliar a funcao pulmonar e forca da musculatura respiratoria no periodo pos-operatorio e verificar o efeito do treinamento muscular inspiratorio sobre as medidas de desempenho da musculatura respiratoria em pacientes submetidos a revascularizacao do miocardio. METODOS: Estudo randomizado, incluindo 47 pacientes submetidos a revascularizacao do miocardio com circulacao extracorporea. Os pacientes foram divididos em grupo controle (GC), 24 pacientes, e grupo estudo (GE) 23 pacientes, com idade media de 66,33 ± 10,20 anos e 61,83 ± 8,61 anos, respectivamente. O GE foi submetido a fisioterapia convencional e ao treinamento muscular inspiratorio com threshold® IMT e o GC a fisioterapia convencional. Foram comparadas as pressoes respiratorias maximas (Pimax e Pemax), volume corrente (VC), capacidade vital (CV) e pico de fluxo expiratorio (Peak Flow) no pre-operatorio (Pre-OP), 1o e 3o dias de pos-operatorio (PO1) e (PO3). RESULTADOS: Observou-se reducao significativa em todas as variaveis mensuradas no PO1, quando comparadas ao pre-operatorio, nos dois grupos estudados, Pimax (P<0,0001), Pemax (P<0,0001), VC: GE (P<0,0004) e GC: (P< 0,0001) e CV GE: (P<0,0001) e GC: (P<0,0001) e peak flow (P<0,0001). No PO3, o GE apresentou em comparacao ao GC, maior valor de CV, GE 1230,4 ± 477,86 ml vs. GC 919,17 ± 394,47 ml (P= 0,0222) e VC GE 608,09 ± 178,24 ml vs. GC 506,96 ± 168,31 ml (P=0,0490). CONCLUSAO: Pacientes submetidos a cirurgia cardiaca sofrem reducao da CV e da forca muscular respiratoria apos a cirurgia. O treinamento muscular realizado foi eficaz em recuperar o VC e a CV no PO3, no grupo treinado.

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.

Treinamento muscular melhora o volume corrente e a capacidade vital no pós-operatório de revascularização do miocárdio

OBJECTIVE To evaluate lung function and respiratory muscle strength in the postoperative period and investigate the effect of inspiratory muscle training on measures of respiratory muscle performance in patients undergoing coronary artery bypass grafting. METHODS A randomized study with 47 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. They were divided into study group (SG) 23 patients and control group (CG) 24 patients, mean age 61.83 ± 8.61 and 66.33 ± 10.20 years, EuroSCORE SG 0.71 ± 0.0018 and CG 0.76 ± 0.0029, respectively. The study group underwent physical therapy and inspiratory muscle training with threshold IMT® and CG underwent conventional physiotherapy. We compared the maximal respiratory pressures (MIP and MEP), tidal volume (TV), vital capacity (VC) and peak expiratory flow (peak flow) preoperatively (Pre-OP), 1st (PO1) and 3rd (PO3) postoperative day. RESULTS There was a significant reduction in all variables measured on PO1 compared to preoperative values in both groups, MIP (P <0.0001), MEP (P <0.0001), TV SG (P <0.0004) and CG (P <0.0001) and VC SG (P <0.0001) and CG (P <0.0001) and peak flow (P <0.0001). At PO3, SG presented higher value of VC, GE 1230.4 ± 477.86 ml vs. GC 919.17 ± 394.47 ml (P=0.0222) and TV SG 608.09 ± 178.24 ml vs. CG 506.96 ± 168.31 ml (P= 0.0490). CONCLUSION Patients undergoing cardiac surgery experience reduced ventilatory capacity and respiratory muscle strength after surgery. Muscle training was performed to retrieve TV and VC in the PO3, in the trained group.OBJETIVO: Avaliar a funcao pulmonar e forca da musculatura respiratoria no periodo pos-operatorio e verificar o efeito do treinamento muscular inspiratorio sobre as medidas de desempenho da musculatura respiratoria em pacientes submetidos a revascularizacao do miocardio. METODOS: Estudo randomizado, incluindo 47 pacientes submetidos a revascularizacao do miocardio com circulacao extracorporea. Os pacientes foram divididos em grupo controle (GC), 24 pacientes, e grupo estudo (GE) 23 pacientes, com idade media de 66,33 ± 10,20 anos e 61,83 ± 8,61 anos, respectivamente. O GE foi submetido a fisioterapia convencional e ao treinamento muscular inspiratorio com threshold® IMT e o GC a fisioterapia convencional. Foram comparadas as pressoes respiratorias maximas (Pimax e Pemax), volume corrente (VC), capacidade vital (CV) e pico de fluxo expiratorio (Peak Flow) no pre-operatorio (Pre-OP), 1o e 3o dias de pos-operatorio (PO1) e (PO3). RESULTADOS: Observou-se reducao significativa em todas as variaveis mensuradas no PO1, quando comparadas ao pre-operatorio, nos dois grupos estudados, Pimax (P<0,0001), Pemax (P<0,0001), VC: GE (P<0,0004) e GC: (P< 0,0001) e CV GE: (P<0,0001) e GC: (P<0,0001) e peak flow (P<0,0001). No PO3, o GE apresentou em comparacao ao GC, maior valor de CV, GE 1230,4 ± 477,86 ml vs. GC 919,17 ± 394,47 ml (P= 0,0222) e VC GE 608,09 ± 178,24 ml vs. GC 506,96 ± 168,31 ml (P=0,0490). CONCLUSAO: Pacientes submetidos a cirurgia cardiaca sofrem reducao da CV e da forca muscular respiratoria apos a cirurgia. O treinamento muscular realizado foi eficaz em recuperar o VC e a CV no PO3, no grupo treinado.

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.

Continuous positive airway pressure increases inspiratory capacity of COPD patients

Background and objective:  Hyperinflation with a decrease in inspiratory capacity (IC) is a common presentation for both unstable and stable COPD patients. As CPAP can reduce inspiratory load, possibly secondary to a reduction in hyperinflation, this study examined whether CPAP would increase IC in stable COPD patients.

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.

Association of the immature platelet fraction with sepsis diagnosis and severity.

Management of Sepsis would greatly benefit from the incorporation of simple and informative new biomarkers in clinical practice. Ideally, a sepsis biomarker should segregate infected from non-infected patients, provide information about prognosis and organ-specific damage, and be accessible to most healthcare services. The immature platelet fraction (IPF) and immature reticulocyte fraction (IRF) are new analytical parameters of the complete blood count, that have been studied as biomarkers of several inflammatory conditions. Recently, a study performed in critically-ill patients suggested that IPF could be a more accurate sepsis biomarker than C-reactive protein (CRP) and procalcitonin. In this retrospective study we evaluated the performance of IPF and IRF as biomarkers of sepsis diagnosis and severity. 41 patients admitted to two intensive care units were evaluated, 12 of which with severe sepsis or septic shock, and 11 with non-complicated sepsis. Significantly higher IPF levels were observed in patients with severe sepsis/septic shock. IPF correlated with sepsis severity scores and presented the highest diagnostic accuracy for the presence of sepsis of all studied clinical and laboratory parameters. No significant differences were observed in IRF levels. Our results suggest that IPF levels could be used as a biomarker of sepsis diagnosis and severity.