Luiz Francisco Poli de Figueiredo

Experimental models of sepsis and septic shock: an overview

Sepsis remains a major cause of morbidity and mortality in surgical patients and trauma victims, mainly due to sepsis-induced multiple organ dysfunction. In contrast to preclinical studies, most clinical trials of promising new treatment strategies for sepsis have fails to demonstrate efficacy. Although many reasons could account for this discrepancy, the misinterpretation of preclinical data obtained from experimental studies, and especially the use of animal models that do not adequately mimic human sepsis may have been contributing factors. In this review, the benefits and limitations of various animal models of sepsis are discussed to clarify the extend to which findings are relevant to human sepsis, particularly with respect to the subsequent design and execution of clinical trials. Such models include intravascular infusion of endotoxin or live bacteria, bacterial peritonitis, cecal ligation and perforation, soft tissue infection, pneumonia or meningitis models, using different animal species including rats, mice, rabbits, dogs, pigs, sheep and nonhuman primates. Despite several limitations, animal models remain essential in the development of all new therapies for sepsis and septic shock, because they provide fundamental information about the pharmacokinetics, toxicity, and mechanism of drug action that cannot be duplicated by other methods. New therapeutic agents should be studies in infection models, even after the initiation of the septic process. Furthermore, debility conditions need to be reproduced to avoid the exclusive use of healthy animals, which often do not represent the human septic patient.

Válvulas da veia braquial comum: estudo anatômico

CONTEXTO: Boa parte das insuficiencias venosas e devida a incompetencia de suas valvulas. Como uma das alternativas cirurgicas, temos os enxertos venosos valvulados no segmento insuficiente. OBJETIVO: Descrever a anatomia das valvulas da veia braquial comum. METODOS: Foram selecionados 30 cadaveres do sexo masculino, independentemente de raca, que tinham seus membros superiores articulados ao tronco. Os mesmos estavam formolizados e foram mantidos em conservacao com solucao de formol a 10%. Utilizamos como criterio de exclusao a existencia de desarticulacao de um dos membros ou de alteracoes deformantes em topografia das estruturas estudadas. RESULTADOS: O numero total de valvulas identificadas foi de 28 em membro superior direito e de 33 em membro superior esquerdo, sendo 15 no segmento proximal direito e 21 no segmento proximal esquerdo. Mais de 91% das valvulas foram do tipo bicuspide e parietal. CONCLUSAO: Conclui-se que a veia braquial comum apresenta frequentemente valvulas do tipo bicuspide e parietal.

Prehospital pediatric trauma classification (PHPTC) as a tool for optimizing trauma care resources in the city of São Paulo, Brazil

PURPOSE To evaluate the pediatric prehospital care in São Paulo, the databases from basic life support units (BLSU) and ALSU, and to propose a simple and effective method for evaluating trauma severity in children at the prehospital phase. METHODS A single firemen headquarter coordinates all prehospital trauma care in São Paulo city. Two databases were analyzed for children from 0 to 18 years old between 1998 and 2001: one from the Basic Life Support Units (BLSU-firemen) and one from the Advanced Life Support Units (ALSU-doctor and firemen). During this period, advanced life support units provided medical reports from 604 victims, while firemen provided 12.761 reports (BLSU+ALSU). Pre-Hospital Pediatric Trauma Classification is based on physiological status, trauma mechanism and anatomic injuries suggesting high energy transfer. In order to evaluate the proposed classification, it was compared to the Glasgow Coma Score and to the Revised Trauma Score. RESULTS There was a male predominance in both databases and the most common trauma mechanism was transport related, followed by falls. Mortality was 1.6% in basic life support units and 9.6% in ALSU. There was association among the proposed score, the Glasgow Coma Score and to the Revised Trauma Score (p<0.0001). CONCLUSION Pre-Hospital Pediatric Trauma Classification is a simple and reliable method for assessment, triage and recruitment of pediatric trauma resources.

Gas tonometry for evaluation of gastrointestinal mucosal perfusion: experimental and clinical sepsis¹. part 2

Evidencias clinicas e experimentais substanciais indicam que o territorio circulatorio mesenterico, principalmente na mucosa intestinal, e altamente vulneravel a reducao na oferta de oxigenio e predisposto a lesao precoce na presenca de alteracoes hemodinâmicas induzidas pela sepse e choque septico. A hipoxia ou isquemia intestinal e um dos possiveis mecanismos contribuintes para a disfuncao da barreira gastrointestinal que pode estar associada com o desenvolvimento da resposta inflamatoria sistemica e com a sindrome da disfuncao de multiplos orgaos, a principal causa comum de morte na sepse. Monitorar a perfusao intestinal na sepse experimental e clinica pode fornecer dados valiosos quanto a novas intervencoes e tratamentos altamente necessarios para reduzir disfuncao de multiplos orgaos e mortalidade extremamente elevadas na sepse. Apresentamos nossa experiencia com a tonometria a gas como monitor da adequacao da perfusao da mucosa gastrointestinal na sepse clinica e experimental, e com o uso de drogas vasoativas no controle hemodinâmico em pacientes com choque septico.

Postnephrectomy arteriovenous fistula

The development of the postnephrectomy arteriovenous fistula (PNAVF) between the renal vessels stumps is rare. Here we present a case report of PNAVF, and review the diagnosis, treatment and prevention. The most common clinical features include a loud murmur over the previous nephrectomy scar, and heart failure resistant to common medical treatment. A 58-year-old white woman was admitted to the hospital for a complete evaluation of an unexplained congestive heart failure with no response to common medical treatment. She had had a right nephrectomy for pyonephrosis 13 years before. The diagnosis of PNAVF was suspected because over the right lumbar region a definite trill was palpated, and on auscultation a harsh, machinery-like murmur was heard. The diagnosis was confirmed by aortogram and selective renal arteriography. In May 1989, the right arteriovenous was excised through a right subcostal transperitoneal approach. The renal vessel stumps were individually ligated and sutured separately close to aorta and vena cava. The patients postoperative course was entirely uneventful in the following seven years. We conclude that during nephrectomy, the renal vessels should be ligated separately, and the transfixation in mass of the stumps avoided to prevent arteriovenous fistula.

Telerobotic-assisted laparoscopic operation performed at a remote site: initial experience

A cirurgia totalmente robotizada e uma opcao a laparoscopia que pode proporcionar alguns beneficios, entre os quais a realizacao dos incansaveis movimentos de repeticao com maior precisao e rapidez e com o cirurgiao localizado em ambiente geograficamente diferente do paciente. Relatamos, em nossa instituicao, a primeira cistectomia totalmente robotizada a distância em um porco (raca Landrace) domestico com o sistema robotico Zeus® (Computer Motion, EUA). A cirurgia foi realizada em duas salas geograficamente separadas, sendo que em uma delas, o porco foi posicionado na mesa cirurgica bem como os bracos do sistema Zeus® fixados de forma segura. Na sequencia, o assistente introduziu os cinco trocateres em forma de leque pela via transperitoneal apos obtencao do pneumoperitonio pelo metodo fechado. Em outra sala, o cirurgiao principal comandava os bracos do robo atraves de controles manuais sentado dentro do console de comando do sistema Zeus ®, auxiliado por imagem de video em tres dimensoes transmitida pelo laparoscopio, que era comandado por sistema de voz, pelo cirurgiao. A distância do console de comando e da mesa cirurgica era de 5 metros e estes estavam conectados por cabos eletricos. A cistectomia total foi realizada em 25 minutos sem intercorrencias. O assistente auxiliou apenas nas manobras de troca de instrumento do sistema Zeus ®, apresentacao dos tecidos e introducao do clipador, utilizando apenas dois trocartes. Os reais beneficios do sistema robotico em nosso meio ainda sera determinado atraves da aquisicao de maior experiencia com o sistema e pelo inicio da realizacao deste procedimento em humanos.

Acta cirúrgica brasileira: novos rumos

Universidade Federal de Sao Paulo (UNIFESP) Depto. de Cirurgia Disciplina de Tecnica Operatoria e Cirurgia Experimental

Pseudoaneurisma artéria femoral pós-angioplastia percutânea de artéria renal

Universidade Federal de Sao Paulo (UNIFESP) Escola Paulista de Medicina Disciplina de Cirurgia Vascular