E Silva

Double-lumen central venous catheters impregnated with chlorhexidine and silver sulfadiazine to prevent catheter colonisation in the intensive care unit setting: a prospective randomised study

Antimicrobial- and antiseptic-impregnated catheters are strategies recommended to prevent central venous catheter (CVC) colonisation. Few data regarding chlorhexidine/silver sulfadiazine-impregnated catheters in intensive care unit (ICU) patients have been reported. We performed a prospective, randomised study comparing the colonisation rates of chlorhexidine/silver sulfadiazine-impregnated CVCs (group 1) against standard CVCs (group 2). In order to assess catheter colonisation rates, a 4cm segment from the tips of aseptically removed catheters was cultured by the roll-plate method. In all, 109 patients were enrolled with successful catheter insertion, 51 of them in group 1 and 58 in group 2. There were no statistically significant differences between the two groups with regards to age, Sequential Organ Failure Assessment (SOFA) score, ICU admission diagnosis, infection risk, catheter insertion sites or catheter length of stay. The colonisation rates were 29.4% (15 catheters) for group 1 and 34.5% (20 catheters) for group 2 (P=0.50). Double-lumen CVCs impregnated with chlorhexidine and silver sulfadiazine were not effective in reducing the incidence of catheter colonisation in ICU patients.

Uma comparação entre a intervenção coronariana percutânea de resgate e primária realizadas no infarto agudo do miocárdio: relato multicêntrico de 9.371 pacientes

OBJECTIVE: To perform a comparative analysis of in-hospital results obtained from AMI patients who underwent rescue or primary PTCA. METHODS: From the Brazilian Interventional National Registry (CENIC), we selected all consecutive patients who underwent a percutaneous coronary intervention for myocardial infarction (< 24 hours), between 1997 and 2000, analyzing those undergoing a rescue (n=840) or a primary (n=8,531) procedure, and comparing their in-hospital results. RESULTS: Rescue patients were significantly younger males with anterior wall infarctions, associated with left ventricular dysfunction, but had less multivessel disease, compared with those treated with primary intervention. Coronary stents were implanted in at similar rates (56.9% vs. 54.9%; P=0.283). Procedural success were lower for rescue cases (88.1% vs. 91.2%; P<0.001), with higher mortality (7.4% vs. 5.6%; P=0.034), compared with the primary intervention group; target vessel revascularization (< 0.5%), emergency bypass surgery (< 0.3%) and reinfarction (< 2.6%) rates were similar for both strategies. Multivariate analysis identified the rescue procedure as a predictor of in-hospital death [OR(CI=95%) = 1.60 (1.17-2.19); P=0.003]. CONCLUSION: Patients who underwent a rescue coronary intervention had higher in-hospital death rates compared with those who underwent a primary coronary intervention.

Comparison between MDCT and Grayscale IVUS in a Quantitative Analysis of Coronary Lumen in Segments with or without Atherosclerotic Plaques.

Background The diagnostic accuracy of 64-slice MDCT in comparison with IVUS has been poorly described and is mainly restricted to reports analyzing segments with documented atherosclerotic plaques. Objectives We compared 64-slice multidetector computed tomography (MDCT) with gray scale intravascular ultrasound (IVUS) for the evaluation of coronary lumen dimensions in the context of a comprehensive analysis, including segments with absent or mild disease. Methods The 64-slice MDCT was performed within 72 h before the IVUS imaging, which was obtained for at least one coronary, regardless of the presence of luminal stenosis at angiography. A total of 21 patients were included, with 70 imaged vessels (total length 114.6 ± 38.3 mm per patient). A coronary plaque was diagnosed in segments with plaque burden > 40%. Results At patient, vessel, and segment levels, average lumen area, minimal lumen area, and minimal lumen diameter were highly correlated between IVUS and 64-slice MDCT (p < 0.01). However, 64-slice MDCT tended to underestimate the lumen size with a relatively wide dispersion of the differences. The comparison between 64-slice MDCT and IVUS lumen measurements was not substantially affected by the presence or absence of an underlying plaque. In addition, 64-slice MDCT showed good global accuracy for the detection of IVUS parameters associated with flow-limiting lesions. Conclusions In a comprehensive, multi-territory, and whole-artery analysis, the assessment of coronary lumen by 64-slice MDCT compared with coronary IVUS showed a good overall diagnostic ability, regardless of the presence or absence of underlying atherosclerotic plaques.

Preliminary results of a prospective randomized study comparing the effect of double-lumen central venous catheters impregnated with chlorhexidine and silver sulfadiazine with the standard on colonization

Central venous catheters (CVC) are frequently used in the intensive care (ICU) setting. A wide number of strategies have been studied to prevent colonization and infection related to CVC. One of them is the use of antimicrobial-impregnated catheters, but no positive effect has been shown primarily for triple-lumen catheters.

Qual o erro da angiografia na definição de isquemia miocárdica durante intervenções coronarianas percutâneas

BACKGROUND: The angiography has been used as a reference standard to define coronary artery disease (CAD), although its limitations are well-known. The significance of the myocardial fractional flow reserve (FFR) in the assessment of CAD is well established. OBJECTIVE: The aim of this study was to evaluate the accuracy of angiography when defining ischemic lesions and its correlation with FFR. METHODS: Two hundred and fifty consecutive patients (471 arteries) were included in this study. All stenoses > 50% at the angiography visual estimate (AVE) were assessed by FFR measurements. When FFR was 0.75, no interventional treatment was carried out. Offline quantitative coronary angiography (QCA) was performed in all stenoses, which were divided in intermediate (< 70% - 327) and severe (125). The correlation coefficients between the diameter of the stenosis (%DS) and FFR and the accuracy of VA of the angiography when assessing ischemia were determined. RESULTS: FFR could be obtained in 452 lesions (96%). Mean %DS and FFR were 56 ± 8% and 0.74 and 76 ± 6% and 0.48 for moderate and severe stenoses, respectively. Concordance between QCA and FFR was poor, especially in intermediate stenoses (Spearmans rho = - 0.33, p<0.0001). Visual assessment resulted in an accuracy of 57% and 96% in intermediate and severe lesions, respectively. CONCLUSION: Neither the visual assessment of an angiogram nor QCA can accurately predict the significance of most intermediate coronary stenoses, which emphasizes the importance of associating it to a functional evaluation of the coronary circulation, resulting in an adequate treatment of these stenoses.

Emprego do stent farmacológico Supralimus, com sirolimus e polímero absorvível, no tratamento de pacientes com síndrome coronária aguda submetidos a intervenção coronária percutânea

BACKGROUND: Despite the efficacy of first generation drug eluting stents in reducing the need of new interventions, its use in more complex conditions, such as acute coronary syndromes, may be associated to higher thrombosis rates. Pre-clinical analyses have attributed a major role to durable polymers in the genesis of these adverse events. The SupralimusTM stent combines a stainless steel platform with a bioabsorbable polymer loaded with sirolimus. This study was aimed at establishing the safety and clinical efficacy of this new drug eluting stent in non-selected acute coronary syndrome patients. METHOD: The E-SERIES Registry is a multicenter and prospective study, including consecutive patients treated with SupralimusTM stent. Virtually all subtypes of patients and lesions are represented in this registry. Information regarding the procedure and clinical outcomes is collected through the internet and adverse events are adjudicated by an independent committee. RESULTS: A total of 1,263 patients were included and 454 (35.9%) had an initial diagnosis of acute coronary syndrome. Most patients were male (68.9%) with mean age of 63 ± 11.4 years. Diabetes mellitus was highly prevalent in this subset (36.8%). Thrombus was visible at pre-intervention angiography in 6% of the cases. Final TIMI 3 flow was achieved in 96.8% of the patients. In-hospital major adverse cardiac events rate was 1% (mortality of 0.4%). Six-month cumulative major adverse cardiac events rate was 10% with 0.4% of stent thrombosis. CONCLUSIONS: The use of SupralimusTM drug eluting stent in the treatment of complex patients with acute coronary syndromes demonstrated excellent performance and safety profile in the midterm follow-up, with low adverse events and thrombosis rates.

Angiografia versus fluxo fracionado de reserva na avaliação do grau de importância das estenoses coronárias

INTRODUCTION: In complex coronary artery disease, it is sometimes difficult to determine which lesions are associated with reversible ischemia. Despite this, the selection of lesions to be stented is often based on the subjectively interpreted angiogram alone. Fractional flow reserve (FFR) is an established objective methodology to indicate which lesions are ischemia-producing. OBJECTIVE: The aim of this study, in patients admitted for elective percutaneous coronary intervention (PCI), was to evaluate the accuracy of angiography in defining culprit lesions, taking FFR as the gold standard, and also its correlation with FFR METHODS: Two hundred and fifty consecutive patients (471 arteries) scheduled for PCI were included in this study. All stenoses > 50% by visual estimation, initially selected to be stented by 3 independent reviewers were assessed by measurement of the FFR. When the FFR was 0.75, no interventional treatment was given. Offline quantitative coronary angiography (QCA) was performed for all stenoses, divided into intermediate (< 70% - 327) and severe (125). The correlation coefficient between the degree of stenosis (%DS) and FFR was determined as was the accuracy of the visual assessment of angiography in evaluating ischemia taking FFR as the gold standard. RESULTS: Optimal FFR readings were obtained in 452 lesions (96%). %DS and FFR were 56 ± 8% and 0.74 for moderate and 76 ± 6% and 0.49 for severe stenosis. Concordance between QCA and FFR was poor especially in intermediate stenosis (Spearmans rho = -0.33, p<.0001). Visual assessment resulted in accuracies of 57% and 96% for intermediate and severe lesions, respectively. CONCLUSIONS: Thus, neither visual assessment of an angiogram nor QCA can accurately predict the significance of most intermediate coronary stenoses, stressing the importance of associating these to a functional evaluation of the coronary circulation which can correctly guide treatment of stenosis.

Costs of sepsis treatment between survivors and nonsurvivors in Brazilian ICUs: does it matter?

Sepsis has been considered a major healthcare problem, upheld by the resources consumed to care for patients with this disease and its high incidence and associated mortality rate. Although we are aware of the high total hospital costs associated with sepsis treatment, even post discharge, the difference in costs of sepsis treatment between survivors and nonsurvivors is an economic analysis that can provide more reliable and interchangeable data. Literature addressing the costs of sepsis management is scant.

Is it possible to obtain Frank–Starling curves in the intensive care unit?

Oxygen delivery depends on cardiac output and oxygen arterial content. Adequate preload is important to optimize cardiac output. Optimal preload can be obtained through Frank–Starling curves, which are difficult to determine at the bedside. Thus, optimal preload is difficult to determine in the intensive care unit.

Dynamic subaortic stenosis with the use of vasoactive drugs in critical care: case report

Although the use of vasoactive drugs is widespread in the critical care setting, its use is associated sometimes with an undesirable hemodynamic outcome. The dynamic subaortic stenosis is a phenomenon described in the echocardiogram stress testing in which patients are submitted to the use of dobutamine. Similarly it could happen in the critical setting where high doses of vasoactives drugs are frequently prescribed, but to our knowledge this has never been described previously.