João Carlos Thomson

Avaliação muscular respiratória nas toracotomias e laparotomias superiores eletivas

OBJECTIVE To identify any possible relation between lower than predicted preoperative respiratory muscle function and the incidence of postoperative respiratory complications and death in elective thoracotomies and laparotomies of the upper abdomen. METHODS A prospective cohort study was conducted, in which 70 patients over the age of 18 were monitored in two similar hospitals. In the preoperative evaluation performed at admission, patients were classified as presenting respiratory muscle function (as determined by measurement of maximal respiratory pressures) > 75% of the predicted value (n = 50) or < 75% of the predicted value (n = 20). Patients were monitored until discharge. In both groups, the incidence of pneumonia was determined, as was that of acute respiratory failure, bronchospasm, prolonged mechanical ventilation, atelectasis, pleural effusion, pneumothorax and death. A comparative analysis was made between the groups, and relative risk was calculated. RESULTS In the study sample, the overall incidence of postoperative complications was 22.86% (16/70): 55% (11/20) in the group of patients presenting < 75% of the predicted value; and 10% (5/50) in the group of patients presenting > 75% of the predicted value. Patients in the < 75% of the predicted value group presented a relative risk of 5.5 (95% confidence interval between 2.19 and 13.82). CONCLUSION Respiratory muscle function below the predicted value was found to be related with higher relative risk of postoperative complications in the surgical procedures studied.

Avaliação de prescrições medicamentosas de um hospital universitário brasileiro

Prescription is the starting point for medicine use. The objective of this work was to identify the quality of the information contained in the prescriptions of a Brazilian university hospital. During the period January 1 to April 30,2004,1.785 drug prescriptions for inpatients older than 12 years were collected. The sample consisted of the total of prescriptions emitted on one day of each week during the study period, observing an interval of 6 days between each collection. Characteristics of the patient, the drug and the prescriber were evaluated. In 230 (12.9%) prescriptions the age of the patient was no mentioned. In 224 (12%) cases the prescriber had not signed the prescription. In 16% of prescriptions at least one item of the information regarding dosage (dosage, pharmaceutical form, route and/or time interval between doses) was missing. The lack of such information represents an obstacle for safe use of medicines and can lead to misuse and adverse reactions. We suggest educative interventions for the professionals who deal with medicines and pharmacotherapeutic monitoring of patients. The participation of the pharmacist in the health team can also contribute to more effective, safe and convenient therapies for the hospitalized patients. Pharmaceutical care and medicine use in Brazilian hospitals need further studies.

Complicações respiratórias no pós-operatório de cirurgias eletivas e de urgência e emergência em um Hospital Universitário

BACKGROUND: Respiratory complications have been the focus of studies aiming to identify methods of reducing postoperative morbidity/mortality and controlling the cost of treatment. OBJECTIVES: To estimate the incidence of the respiratory complications in patients submitted to elective or urgent/emergency surgical procedures and determine any correlations between respiratory complications and potential risk factors. METHOD: A retrospective cohort study of patients submitted to elective or urgent/emergency surgery at a university hospital during 2001. The sample was restricted to patients hospitalized for at least 24 hours following surgery. Data were collected from patient charts and according to protocol. RESULTS: Of the 5075 patients submitted to elective or urgent/emergency surgery during the year 2001, 1345 (25.5%) were included in the study. There was no statistically significant difference between elective surgery and urgent/emergency surgery in terms of respiratory complications. The incidence of respiratory complications was 11.7%. The most frequent complication (at 52.5%) was pneumonia. Overall mortality was 7.2% and 27.8% of deaths were related to respiratory complications. CONCLUSION: The incidence of postoperative respiratory complications was 11.7% (11.3% in elective surgery and 12.3% in urgent/emergency surgery). Pneumonia was the most frequent complication. The risk factors that correlated with respiratory complications were previous lung disease, use of a nasogastric tube, admission to the intensive care unit, endotracheal intubation and tracheostomy.

Doença de Castleman ou hiperplasia angiofolicular como nódulo pulmonar solitário: relato de caso

Castleman disease is a rare disorder generally characterized by a mediastinal nodule, with a great variety of alternative presentations regarding age, clinical manifestations and evolution. This case report describes a 40-year-old female patient presenting with uncharacteristic chest pain for a few years. A chest X-ray revealed a hypotransparency on the right side. Computed tomography and pulmonary arteriography did not elucidate the diagnosis, which was made through surgical resection and anatomopathological examination of the nodule, which presented characteristics of angiofollicular hyperplasia, or Castleman disease. This article emphasizes the importance of adding this disease to the list of morbidities in the differential diagnosis of pulmonary solitary nodules.

Comportamento da função pulmonar, força muscular respiratória e qualidade de vida em pacientes submetidos às toracotomias eletivas

OBJECTIVE To evaluate pre-and postoperative pulmonary function, respiratory muscle strength and quality of life in patients submitted to elective thoracotomy. METHODS We selected 19 patients undergoing elective thoracotomy to assess the following parameters: forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and quality of life through implementation of the SF-36. The examinations were performed preoperatively and in the second, 10th, 15th, 30th and 60th days postoperatively. We conduced data normality analyzes were made with the Shapiro-Wilk test, descriptive analysis of the study variables, as well as analysis of variance with multiple comparisons using ANOVA and Friedman, p-value <0.05 . RESULTS There was a significant decrease in spirometric levels and in maximal respiratory pressures in the second postoperative day. FVC returned to preoperative values between the 15th and 30th postoperative days, whereas FEV1, between the 10th and 15th. MIP and MEP returned to preoperative values between the 10th and 15th postoperative days. There was a decrease in quality of life as for functional capacity and physical aspects, which returned to preoperative values within two months after surgery. CONCLUSION There was significant reduction in lung function and respiratory muscle strength, which returned to baseline within 30 days after surgery. There was a decrease in quality of life that persisted for up to 60 days after the operation.

Drenagem torácica pós-pneumonectomia: sim ou não? Estudo retrospectivo

OBJECTIVE: To evaluate the need for post-pneumonectomy thoracic drainage. METHODS: This was a retrospective study of 46 patients having undergone pneumonectomy in the Thoracic Surgery Department of the Londrina University Hospital between January of 1998 and December of 2004. Patients were divided into two groups: those having been submitted to drainage and those not having been. The diseases involved were lung cancer, bronchiectasis and tuberculosis. RESULTS: Drainage was used in 21 patients, whereas no drainage was used in 25. The most common postoperative complication was subcutaneous emphysema (12 cases). Hospital stays were of shorter duration among patients who were not submitted to drainage than among those who were (mean, 6.5 days vs. 10.2 days). No serious postoperative complications were observed in the group of patients not submitted to drainage. CONCLUSION: The findings that evolutions were more favorable and hospital stays were shorter for the patients not submitted to drainage call into question the need for routine post-pneumonectomy drainage.

Hemopneumotórax espontâneo: uma rara entidade clínica

Spontaneous hemopneumothorax with massive bleeding is considered a rare complication of spontaneous pneumothorax. The authors describe two patients with acute chest pain and dyspnea; the chest X-ray showed pneumothorax and pleural effusion. The two cases were submitted to thoracic drainage and presented important bleeding; thoracotomy was performed and in the first case an aberrant vessel was found, and in the second case the source of bleeding was rupture of pleural adherence. The post-operative evolution had no incidents in either case.

Mortes evitáveis em pacientes de trauma associadas a não adesão às diretrizes de atendimento.

OBJECTIVES: To evaluate patients treated for traumatic injuries and to identify adherence to guidelines recommendations of treatment and association with death. The recommendations adopted were defined by the committee on trauma of the American College of Surgeons in advanced trauma life support. METHODS: Retrospective cohort study conducted at a teaching hospital. The study population was victims of trauma > 12 years of age with injury severity scores > 16 who were treated between January 1997 and December 2001. Data collection was divided into three phases: pre-hospital, in-hospital, and post-mortem. The data collected were analyzed using EPI INFO. RESULTS: We analyzed 207 patients, 147 blunt trauma victims (71%) and 60 (29%) penetrating trauma victims. Trauma victims had a 40.1% mortality rate. We identified 221 non adherence events that occurred in 137 patients. We found a mean of 1.61 non adherence per patient, and it occurred less frequently in survivors (1.4) than in non-survivors (1.9; p=0.033). According to the trauma score and injury severity score methodology, 54.2% of deaths were considered potentially preventable. Non adherence occurred 1.77 times more frequently in those considered potentially preventable deaths compared to other non-survivors (95% CI: 1.12-2.77; p=0.012), and 92.9% of the multiple non adherence occurred in the first group (p=0.029). CONCLUSIONS: Non adherence occurred more frequently in patients with potentially preventable deaths. Non adherence to guidelines recommendations can be considered a contributing factor to death in trauma victims and can lead to an increase in the number of potentially preventable deaths.