Domingos Dias Cicarelli

Early dexamethasone treatment for septic shock patients: a prospective randomized clinical trial

CONTEXT AND OBJECTIVE Sepsis and septic shock are very common conditions among critically ill patients that lead to multiple organ dysfunction syndrome (MODS) and death. Our purpose was to investigate the efficacy of early administration of dexamethasone for patients with septic shock, with the aim of halting the progression towards MODS and death. DESIGN AND SETTING Prospective, randomized, double-blind, single-center study, developed in a surgical intensive care unit at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo. METHODS The study involved 29 patients with septic shock. All eligible patients were prospectively randomized to receive either a dose of 0.2 mg/kg of dexamethasone (group D) or placebo (group P), given three times at intervals of 36 hours. The patients were monitored over a seven-day period by means of the sequential organ failure assessment score. RESULTS Patients treated with dexamethasone did not require vasopressor therapy for as much time over the seven-day period as did the placebo group (p = 0.043). Seven-day mortality was 67% in group P (10 out of 15) and 21% in group D (3 out of 14) (relative risk = 0.31, 95% confidence interval 0.11 to 0.88). Dexamethasone enhanced the effects of vasopressor drugs. CONCLUSIONS Early treatment with dexamethasone reduced the seven-day mortality among septic shock patients and showed a trend towards reduction of 28-day mortality.

Comparison of C-Reactive Protein and Serum Amyloid A Protein in Septic Shock Patients

Septic shock is a severe inflammatory state caused by an infectious agent. Our purpose was to investigate serum amyloid A (SAA) protein and C-reactive protein (CRP) as inflammatory markers of septic shock patients. Here we evaluate 29 patients in postoperative period, with septic shock, in a prospective study developed in a surgical intensive care unit. All eligible patients were monitored over a 7-day period by sequential organ failure assessment (SOFA) score, daily CRP, SAA, and lactate measurements. CRP and SAA strongly correlated up to the fifth day of observation but were not good predictors of mortality in septic shock.

Effects of single dose of dexamethasone on patients with systemic inflammatory response

CONTEXT AND OBJECTIVE Systemic inflammatory response syndrome (SIRS) is a very common condition among critically ill patients. SIRS, sepsis, septic shock and multiple organ dysfunction syndrome (MODS) can lead to death. Our aim was to investigate the efficacy of a single dose of dexamethasone for blocking the progression of systemic inflammatory response syndrome. DESIGN AND SETTING Prospective, randomized, double-blind, single-center study in a postoperative intensive care unit (Surgical Support Unit) at Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. METHODS The study involved 29 patients with SIRS. All eligible patients were prospectively randomized to receive either a single dose of 0.2 mg/kg of dexamethasone or placebo, after SIRS was diagnosed. The patients were monitored over a seven-day period using Sequential Organ Failure Assessment score (SOFA). RESULTS The respiratory system showed an improvement on the first day after dexamethasone was administered, demonstrated by the improved PaO2/FiO2 ratio (p < 0.05). The cardiovascular system of patients requiring vasopressor therapy also improved over the first two days, with a better evolution in the dexamethasone group (p < 0.05). Non-surviving patients presented higher lactate assays than did survivors (p < 0.05) during this period. CONCLUSIONS Dexamethasone enhanced the effects of vasopressor drugs and evaluation of the respiratory system showed improvements (better PaO2/FiO2 ratio), one day after its administration. Despite these improvements, the single dose of dexamethasone did not block the evolution of SIRS.

Manobra de recrutamento alveolar em anestesia: como, quando e por que utilizá-la

JUSTIFICATIVA Y OBJETIVOS: La maniobra de reclutamiento alveolar (MRA) consiste en la reabertura de areas pulmonares colapsadas a traves del aumento de la presion inspiratoria en la via aerea, utilizada principalmente en pacientes con Sindrome del Desaliento Respiratorio Agudo. Este estudio tuvo como objetivo evaluar la aplicacion de la MRA en anestesia, como realizarla y en cuales situaciones clinicas. METODO: Revision de la literatura a traves de la base de datos MedLine, en el periodo transcurrido entre 1993 a 2004. RESULTADOS: La forma mas utilizada para realizacion de la MRA es la insuflacion sostenida por el modo CPAP con presiones que varian de 30 a 40 cmH2O por 30 a 90 segundos. Las cirugias laparoscopicas, las cirugias con ventilacion monopulmonar, cirugias cardiacas, pacientes obesos y pacientes pediatricos fueron las situaciones clinicas en que la MRA trajo beneficio a los pacientes. CONCLUSIONES: La MRA puede ser util en la practica anestesica, mejorando la oxigenacion postoperatoria y deshaciendo atelectasias de pacientes sometidos a anestesia general.BACKGROUND AND OBJECTIVES Alveolar recruitment maneuver (ARM) is the reopening of lung tissue collapsed by increased airway inspiratory pressure, primarily performed in patients with acute respiratory distress syndrome. This study aimed at evaluating ARM in anesthesia, how to do it and in which clinical situations. METHODS Literature review using MedLine database in the period 1993 to 2004. RESULTS Most common approach for recruitment maneuver is sustained inflation by CPAP with pressures varying from 30 to 40 cmH2O for 30 to 90 seconds. ARM was beneficial during laparoscopic procedures, single-lung ventilation surgeries and cardiac surgeries, and for obese and pediatric patients. CONCLUSIONS Recruitment maneuver may be useful for anesthetic practice, improving postoperative oxygenation and re-expanding atelectasis of anesthetized patients.

C-reactive protein is not a useful indicator for infection in surgical intensive care units

CONTEXT AND OBJECTIVE C-reactive protein (CRP) is commonly used as a marker for inflammatory states and for early identification of infection. This study aimed to investigate CRP as a marker for infection in patients with postoperative septic shock. DESIGN AND SETTING Prospective, single-center study, developed in a surgical intensive care unit at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo. METHODS This study evaluated 54 patients in the postoperative period, of whom 29 had septic shock (SS group) and 25 had systemic inflammatory response syndrome (SIRS group). All of the patients were monitored over a seven-day period using the Sequential Organ Failure Assessment (SOFA) score and daily CRP and lactate measurements. RESULTS The daily CRP measurements did not differ between the groups. There was no correlation between CRP and lactate levels and the SOFA score in the groups. We observed that the plasma CRP concentrations were high in almost all of the patients. The patients presented an inflammatory state postoperatively in response to surgical aggression. This could explain the elevated CRP measurements, regardless of whether the patient was infected or not. CONCLUSIONS This study did not show any correlation between CRP and infection among patients with SIRS and septic shock during the early postoperative period.

Embolia gasosa por dióxido de carbono durante cirurgia laparoscópica: relato de caso

BACKGROUND AND OBJECTIVES: Carbon dioxide gas embolism is an uncommon but potentially lethal complication of laparoscopic surgery. Our report aimed at describing a case of pulmonary carbon dioxide embolism with favorable evolution. CASE REPORT: Hypertensive patient was submitted to laparoscopic surgery under general anesthesia due to cholelithiasis. After 150 minutes of pneumoperitoneum, patient developed tachycardia with severe hemodynamic deterioration, despite the use of vasopressor drugs. Arterial blood-gas revealed major difference between PaCO2 and PETCO2. Carbon dioxide embolism was suspected and pneumoperitoneum was immediately deflated. Surgery was converted to a conventional technique. Patient has evolved with hemodynamic improvement and was extubated at surgery completion, being referred to post-anesthetic care unit (PACU). CONCLUSIONS: Early diagnosis and immediate treatment resulted in positive outcome in this case.

Bloqueio combinado para analgesia de parto: a adição de sufentanil ao anestésico local influencia o apgar dos recém-nascidos?

JUSTIFICATIVA E OBJETIVOS: O bloqueio combinado (BC) e uma tecnica muito utilizada em anestesia obstetrica. Porem nao ha na literatura padronizacao com relacao a tecnica, doses e anestesicos utilizados, alem da controversia sobre a possibilidade da adicao do opioide ao anestesico local causar bradicardia fetal e alteracao de sua vitalidade. O objetivo deste estudo foi identificar as tecnicas e anestesicos utilizados no Servico de Anestesiologia do Hospital Universitario da Universidade de Sao Paulo (USP) e avaliar se a utilizacao de sufentanil associado ao anestesico local no BC altera o Apgar dos recem-nascidos. METODO: Foram analisadas as fichas de anestesia em que foram realizados BC para analgesia de parto durante 12 meses no Hospital Universitario da USP. Foram registrados o uso e dose de sufentanil, a via de parto utilizada e os escores de Apgar do 1°, 5° e 10° minutos dos recem-nascidos. RESULTADOS: Dos 635 BC avaliados, 307 utilizaram sufentanil e anestesico local (Grupo SUF) e 328, so anestesico local (Grupo AL). Cento e vinte e sete (20%) foram realizados atraves da tecnica de agulha por dentro de agulha e os outros 508 (80%) foram realizados pela tecnica de duas puncoes. Nao foi verificada diferenca entre o Apgar dos grupos estudados no 1°, 5° e 10° minutos. CONCLUSOES: O sufentanil utilizado no bloqueio combinado nao alterou o Apgar dos recem-nascidos.BACKGROUND AND OBJECTIVES Combined spinal-epidural (CSE) is a very common obstetric technique. However, the literature does not present a standardization regarding the technique, doses, and anesthetics used, besides there is also the controversy about the possibility that the addition of opioids to the local anesthetic causes fetal bradycardia and affects its vitality. The aim of this study was to identify the techniques and anesthetics used in the Anesthesiology Service of the Hospital Universitário of Universidade de São Paulo (USP) and determine whether the use of sufentanil associated with the local anesthetic affects Apgar scores of newborns. METHODS The anesthesiology charts of patients submitted to CSE for labor analgesia over a 12-month period at the Hospital Universitário of USP were analyzed. The use and dose of sufentanil, the type of delivery, and Apgar scores in the 1st, 5th, and 10th minutes were recorded. RESULTS Of the 635 CSE analyzed, 307 used sufentanil and local anesthetic (SUF Group) and 328 only local anesthetic (LA Group). One hundred and twenty-seven (20%) were done using the needle through the needle technique and the other 508 (80%) used the double puncture technique. There were no differences in the Apgar scores in the 1st, 5th, and 10th minutes between both groups. CONCLUSIONS The use of sufentanil in the combined spinal-epidural did not change Apgar scores of the newborns.

Lactato como prognóstico de mortalidade e falência orgânica em pacientes com síndrome da resposta inflamatória sistêmica

BACKGROUND AND OBJECTIVES The systemic inflammatory response syndrome (SIRS) is common in the postoperative period of critically ill patients. The objective of this study was to investigate the correlation between lactate level, multiple organ dysfunction, and mortality in patients with SIRS. METHODS This prospective study evaluated 24 patients with a postoperative diagnosis of SIRS (American College of Chest Physicians/Society of Critical Care Medicine) in the surgical ICU. Lactate levels were determined in the first 24 hours after the diagnosis of SIRS and daily, for 7 days. Patients were divided in 2 groups: LE Group (lactate > 2 mmol.L-1) and LN Group (lactate < 2 mmol.L-1). Multiple organ failure was evaluated by the SOFA (Sequential Organ Failure Assessment) score daily, for 7 days. After the 7-day follow-up period patients were followed for up to 28 days, until discharge from the hospital or death. RESULTS Thirteen patients were included in the LE Group after the diagnosis of SIRS and 11 patients in the LN Group. The relative risk (RR) of death in 7 days for the LE Group was 4.23 (CI 95% 2.25-7.95) times greater than in the LN Group in the first day of the study. The RR of death in 28 days was 1.7 times greater for the LE Group (CI 95% 0.84-3.46). The SOFA score was similar in both groups. CONCLUSIONS Patients with elevated lactate in the first 24 hours after the diagnosis of SIRS did not have more organic dysfunction than patients with normal lactate levels, but they had an increased risk of death in 7 days.

Lactate as a predictor of mortality and multiple organ failure in patients with the systemic inflammatory response syndrome

BACKGROUND AND OBJECTIVES The systemic inflammatory response syndrome (SIRS) is common in the postoperative period of critically ill patients. The objective of this study was to investigate the correlation between lactate level, multiple organ dysfunction, and mortality in patients with SIRS. METHODS This prospective study evaluated 24 patients with a postoperative diagnosis of SIRS (American College of Chest Physicians/Society of Critical Care Medicine) in the surgical ICU. Lactate levels were determined in the first 24 hours after the diagnosis of SIRS and daily, for 7 days. Patients were divided in 2 groups: LE Group (lactate > 2 mmol.L-1) and LN Group (lactate < 2 mmol.L-1). Multiple organ failure was evaluated by the SOFA (Sequential Organ Failure Assessment) score daily, for 7 days. After the 7-day follow-up period patients were followed for up to 28 days, until discharge from the hospital or death. RESULTS Thirteen patients were included in the LE Group after the diagnosis of SIRS and 11 patients in the LN Group. The relative risk (RR) of death in 7 days for the LE Group was 4.23 (CI 95% 2.25-7.95) times greater than in the LN Group in the first day of the study. The RR of death in 28 days was 1.7 times greater for the LE Group (CI 95% 0.84-3.46). The SOFA score was similar in both groups. CONCLUSIONS Patients with elevated lactate in the first 24 hours after the diagnosis of SIRS did not have more organic dysfunction than patients with normal lactate levels, but they had an increased risk of death in 7 days.

Alveolar recruitment maneuver in anesthetic practice: how, when and why it may be useful

JUSTIFICATIVA Y OBJETIVOS: La maniobra de reclutamiento alveolar (MRA) consiste en la reabertura de areas pulmonares colapsadas a traves del aumento de la presion inspiratoria en la via aerea, utilizada principalmente en pacientes con Sindrome del Desaliento Respiratorio Agudo. Este estudio tuvo como objetivo evaluar la aplicacion de la MRA en anestesia, como realizarla y en cuales situaciones clinicas. METODO: Revision de la literatura a traves de la base de datos MedLine, en el periodo transcurrido entre 1993 a 2004. RESULTADOS: La forma mas utilizada para realizacion de la MRA es la insuflacion sostenida por el modo CPAP con presiones que varian de 30 a 40 cmH2O por 30 a 90 segundos. Las cirugias laparoscopicas, las cirugias con ventilacion monopulmonar, cirugias cardiacas, pacientes obesos y pacientes pediatricos fueron las situaciones clinicas en que la MRA trajo beneficio a los pacientes. CONCLUSIONES: La MRA puede ser util en la practica anestesica, mejorando la oxigenacion postoperatoria y deshaciendo atelectasias de pacientes sometidos a anestesia general.BACKGROUND AND OBJECTIVES Alveolar recruitment maneuver (ARM) is the reopening of lung tissue collapsed by increased airway inspiratory pressure, primarily performed in patients with acute respiratory distress syndrome. This study aimed at evaluating ARM in anesthesia, how to do it and in which clinical situations. METHODS Literature review using MedLine database in the period 1993 to 2004. RESULTS Most common approach for recruitment maneuver is sustained inflation by CPAP with pressures varying from 30 to 40 cmH2O for 30 to 90 seconds. ARM was beneficial during laparoscopic procedures, single-lung ventilation surgeries and cardiac surgeries, and for obese and pediatric patients. CONCLUSIONS Recruitment maneuver may be useful for anesthetic practice, improving postoperative oxygenation and re-expanding atelectasis of anesthetized patients.