Matheus Fachini Vane

Opinião dos médicos das Unidades de Terapia Intensiva do Complexo Hospital das Clínicas sobre a ortotanásia

JUSTIFICATIVA E OBJETIVOS: A medicina atual vive um momento de busca de sensato equilibrio na relacao medico-paciente. Contrariamente ao que se observava poucos anos atras, onde o paciente era, na estrita concepcao da palavra, um paciente, ou seja, aquele que so obedece sem questionar, hoje ele e considerado um agente autonomo, que participa ativamente decidindo sobre ele mesmo. Ao mesmo tempo, a medicina incorporou tecnicas, medicamentos e procedimentos que podem, por si so, manter a vida do paciente quase que indefinidamente, mesmo que esta seja totalmente vegetativa. O objetivo deste estudo foi avaliar o impacto da resolucao CFM 1.805/2006 na opiniao dos medicos que trabalham nas Unidades de Terapia Intensiva (UTI) do Complexo Hospital das Clinicas. METODO: Apos aprovacao pela Comissao de Etica em Pesquisa da Instituicao foram entrevistados 100 medicos que exercem atividade nas unidades de terapia intensiva do Complexo Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo no ano de 2007, sendo 41 medicos assistentes e 59 residentes. RESULTADOS: Todos os entrevistados foram favoraveis a ortotanasia, 67% consideraram a resolucao como ideal e 26% como adequada, tendo apenas uma minoria de 7% considerando-a inadequada. Dos medicos entrevistados, 93% ja pensaram na possibilidade de colocar a ortotanasia em pratica. CONCLUSAO: A maioria dos medicos foi favoravel a pratica da ortotanasia, principio que visa diminuir o sofrimento do paciente e de seus familiares, desde que respeitada a vontade da pessoa ou de seu representante legal, devidamente fundamentada e registrada no prontuario e que o paciente continue a receber todos os cuidados necessarios para aliviar os sintomas que levam ao sofrimento, sendo assegurada a assistencia integral, o conforto fisico, psiquico, social e espiritual, e o direito a alta hospitalar.

Comparação dos efeitos da dobutamina e da milrinona sobre a hemodinâmica e o transporte de oxigênio em pacientes submetidos à cirurgia cardíaca com baixo débito cardíaco após indução anestésica

BACKGROUND AND OBJECTIVES: Several classes of inotropic drugs with different hemodynamic effects are used in the treatment of low cardiac output in patients with diastolic dysfunction undergoing cardiac surgery. The objective of the present study was to compare the effects of dobutamine and milrinone on hemodynamic parameters and oxygen supply in this population of patients. METHODS: After approval by the Ethics Committee of the institution and signing of the informed consent, 20 patients undergoing cardiac surgery with cardiac index < 2 L.min-1.m2 after anesthetic induction and place ment of a pulmonary artery catheter were randomly divided to receive dobutamine 5 µg.kg-1. min-1 (n = 10), or milrinone 0.5 µg.kg-1.min-1 (n = 10). Hemodynamic parameters were measured after anesthetic induction and after 30 and 60 minutes, and arterial and venous blood gases were measured at baseline and 60 minutes. Non-paired Student t test or two-way ANOVA for repeated measurements was used to compare the data. RESULTS: Dobutamine and milrinone promoted significant increases in cardiac index (56% and 47%) and oxygen supply (53% and 45%), and reduction in systemic (33% and 36%) and pulmonary (34% and 19%) vascular resistance, respectively. However, statistically significant differences were not observed between both drugs. CONCLUSIONS: Both inotropic drugs were similarly effective in restoring tissue blood flow and oxygen supply to adequate levels in patients with low cardiac output undergoing cardiac surgery.

Comparison of the Effects of Dobutamine and Milrinone on Hemodynamic Parameters and Oxygen Supply in Patients Undergoing Cardiac Surgery with Low Cardiac Output after Anesthetic Induction

BACKGROUND AND OBJECTIVES Several classes of inotropic drugs with different hemodynamic effects are used in the treatment of low cardiac output in patients with diastolic dysfunction undergoing cardiac surgery. The objective of the present study was to compare the effects of dobutamine and milrinone on hemodynamic parameters and oxygen supply in this population of patients. METHODS After approval by the Ethics Committee of the institution and signing of the informed consent, 20 patients undergoing cardiac surgery with cardiac index < 2 L*min(-1)*m(2) after anesthetic induction and placement of a pulmonary artery catheter were randomly divided to receive dobutamine 5 microg*kg(-1). min(-1) (n = 10), or milrinone 0.5 microg*kg(-1)*min(-1) (n = 10). Hemodynamic parameters were measured after anesthetic induction and after 30 and 60 minutes, and arterial and venous blood gases were measured at baseline and 60 minutes. Non-paired Student t test or two-way ANOVA for repeated measurements was used to compare the data. RESULTS Dobutamine and milrinone promoted significant increases in cardiac index (56% and 47%) and oxygen supply (53% and 45%), and reduction in systemic (33% and 36%) and pulmonary (34% and 19%) vascular resistance, respectively. However, statistically significant differences were not observed between both drugs. CONCLUSIONS Both inotropic drugs were similarly effective in restoring tissue blood flow and oxygen supply to adequate levels in patients with low cardiac output undergoing cardiac surgery.

Myocardial protection induced by fentanyl in pigs exposed to high-dose adrenaline

The use of high doses of adrenaline is common in critical patients, especially during cardiac arrest. During these situations, myocardial dysfunction can be a result of multiple factors, including adrenaline use. In addition, opioids have been shown to have anti‐arrhythmic and anti‐ischemic mechanisms that may confer cardiac protection. This study aimed to evaluate the effects of fentanyl on myocardial function in pigs exposed to high‐dose adrenaline. After institutional ethics committee approval, 26 pigs were randomly allocated to receive either 20 μg/kg fentanyl (n = 10; fentanyl group) administered 5 min before five doses of adrenaline (20 μg/kg), equivalent‐volume saline (n = 10; saline group) using the same adrenaline dosing protocol, or neither fentanyl nor adrenaline (n = 6; sham group). The fentanyl group showed lower levels of troponin at the end of the sixth hour compared with the saline group (1.91 ± 1.47 vs 5.44 ± 5.35 ng/mL, P = 0.019). Transmission electron microscopy and immunohistochemistry also showed less myocardial injury in the fentanyl group. The conclusion was reached that fentanyl attenuates myocardial injury caused by high‐dose adrenaline without blunting the hemodynamic effect of adrenaline.

Sevoflurane preconditioning during myocardial ischemia-reperfusion reduces infarct size and preserves autonomic control of circulation in rats

PURPOSE To investigate the myocardial ischemia-reperfusion with sevoflurane anesthetic preconditioning (APC) would present beneficial effects on autonomic and cardiac function indexes after the acute phase of a myocardial ischemia-reperfusion. METHODS Twenty Wistar rats were allocated in three groups: control (CON, n=10), myocardial infarction with sevoflurane (SEV, n=5) and infarcted without sevoflurane (INF, n=5). Myocardial ischemia (60 min) and reperfusion were performed by temporary coronary occlusion. Twenty-one days later, the systolic and diastolic function were evaluated by echocardiography; spectral analysis of the systolic arterial pressure (SAPV) and heart rate variability (HRV) were assessed. After the recording period, the infarct size (IS) was evaluated. RESULTS The INF group presented greater cardiac dysfunction and increased sympathetic modulation of the SAPV, as well as decreased alpha index and worse vagal modulation of the HRV. The SEV group exhibited attenuation of the systolic and diastolic dysfunction and preserved vagal modulation (square root of the mean squared differences of successive R-R intervals and high frequency) of HRV, as well as a smaller IS. CONCLUSION Sevoflurane preconditioning better preserved the cardiac function and autonomic modulation of the heart in post-acute myocardial infarction period.

Effects of propofol in lipid-based emulsion and in microemulsion on the incidence of endothelial lesion in rabbits

PURPOSE To compare the incidence of endothelial injury after single-dose or continuous propofol infusion in conventional lipid-based emulsion (LE) versus microemulsion (ME). METHODS Forty-two rabbits (2.5-4.5 Kg) were randomly allocated into seven groups of six animals each: SHAM- surgical treatment alone; Bolus Control Group - 3 mL-intravenous (IV) bolus of saline; Continuous Infusion Control Group - 3 mL- IV bolus of saline followed by a continuous infusion of 0.2 ml/kg/min for 60 min; Bolus LE Propofol Group - IV bolus of LE propofol (3 mg/kg); Bolus ME Propofol Group - IV ME propofol bolus (3 mg/kg); Continuous LE Propofol Group - IV LE propofol bolus (3 mg/kg) followed by a continuous infusion of 0.2 ml/kg/min for 60 min; Continuous ME Propofol Group - IV ME propofol bolus (3 mg/kg) followed by a continuous infusion of 0.2 ml/kg/min for 60 min. RESULTS There were no statistically significant differences between the studied groups in blood pressure, in central venous pressure and in the biochemical profile. No significant differences were found in inflammatory mediators and in tissue analysis between the two emulsions. CONCLUSION Microemulsion and lipid-based emulsion propofol had similar inflammatory, biochemical and microscopy profiles. Thus, microemulsion propofol can be used as an alternative to lipid-based emulsion propofol.

Perioperative cardiac arrest: an evolutionary analysis of the intra-operative cardiac arrest incidence in tertiary centers in Brazil

BACKGROUND Great changes in medicine have taken place over the last 25 years worldwide. These changes in technologies, patient risks, patient profile, and laws regulating the medicine have impacted the incidence of cardiac arrest. It has been postulated that the incidence of intraoperative cardiac arrest has decreased over the years, especially in developed countries. The authors hypothesized that, as in the rest of the world, the incidence of intraoperative cardiac arrest is decreasing in Brazil, a developing country. OBJECTIVES The aim of this study was to search the literature to evaluate the publications that relate the incidence of intraoperative cardiac arrest in Brazil and analyze the trend in the incidence of intraoperative cardiac arrest. CONTENTS There were 4 articles that met our inclusion criteria, resulting in 204,072 patients undergoing regional or general anesthesia in two tertiary and academic hospitals, totalizing 627 cases of intraoperative cardiac arrest. The mean intraoperative cardiac arrest incidence for the 25 years period was 30.72:10,000 anesthesias. There was a decrease from 39:10,000 anesthesias to 13:10,000 anesthesias in the analyzed period, with the related lethality from 48.3% to 30.8%. Also, the main causes of anesthesia-related cause of mortality changed from machine malfunction and drug overdose to hypovolemia and respiratory causes. CONCLUSIONS There was a clear reduction in the incidence of intraoperative cardiac arrest in the last 25 years in Brazil. This reduction is seen worldwide and might be a result of multiple factors, including new laws regulating the medicine in Brazil, incorporation of technologies, better human development level of the country, and better patient care.

Successful liver allograft inflow reconstruction with the right gastroepiploic vein

Portal vein thrombosis is a common complication in cirrhotic patients. When portal vein thrombectomy is not a suitable option, a large collateral vessel can be used for allograft venous inflow reconstruction. We describe an unusual case of successful portal revascularization using the right gastroepiploic vein. The patient underwent a cadaveric orthotopic liver transplantation with end-to-end anastomosis of the portal vein to the right gastroepiploic vein. Six months after liver transplantation the patient is well with good liver function. The use of the right gastroepiploic vein for allograft venous reconstruction is feasible and safe, with a great advantage of avoiding the need of venous jump graft.

Effects of catecholamines on volemic replacement with saline solution and the impact on heart rate variability in rabbits subjected to hemorrhage. A study by spectral analysis

PURPOSE To verify the effects of different catecholamines on volemic expansion and on the autonomic nervous system in rabbits that were subjected to hemorrhage. METHODS Twenty four rabbits subjected to hemorrhage (with a 25% loss of blood volume) and were randomly divided into four experimental groups: 1) HEMO Group underwent replacement with their own blood in an equal volume; 2) SS Group underwent replacement with saline solution (SS) in a volume that corresponded to three times the removed blood volume; 3) ISP Group underwent replacement with SS and isoprenaline; 4) FNL Group underwent replacement with SS and phenylephrine. Spectral Analysis of the heart rate and heart rate variability were performed from the recorded data. Hematocrit was measured throughout the experiment. RESULTS Replacement with SS and an α- or β-agonist did not produce differences in the intravascular retention compared to replacement with SS alone. An analysis of HRV showed that the FNL group maintained the LF/HF ratio better than ISP and SS. CONCLUSIONS No difference in vascular retention when α- or β- agonists were added to SS during post-hemorrhagic recovery. The animals in the FNL group maintained the integrity of the autonomic response within normal physiological standards during hemorrhagic stress.

É improvável que a cirurgia seja suficiente para que o paciente pare de fumar 24 horas antes da internação hospitalar

INTRODUCTION The need for surgery can be a decisive factor for long-term smoking cessation. On the other hand, situations that precipitate stress could precipitate smoking relapse. The authors decided to study the impact of a surgery on the patients effort to cease smoking for, at least, 24h before hospital admission and possible relapse on the last 24h before hospital admission for ex-smokers. METHODS Smoker, ex-smokers and non-smokers adults, either from pre-anesthetic clinic or recently hospital admitted for scheduled elective surgeries that were, at most, 6h inside the hospital buildings were included in the study. The patients answered a questionnaire at the ward or at the entrance of the operating room (Admitted group) or at the beginning of the first pre-anesthetic consultation (Clinic group) and performed CO measurements. RESULTS 241 patients were included, being 52 ex-smokers and 109 never smokers and 80 non-smokers. Smokers had higher levels of expired carbon monoxide than non-smokers and ex-smokers (9.97±6.50 vs. 2.26±1.65 vs. 2.98±2.69; p=0.02). Among the smokers, the Clinic group had CO levels not statistically different of those on the Admitted group (10.93±7.5 vs. 8.65±4.56; p=0.21). The ex-smokers presented with no significant differences for the carbon monoxide levels between the Clinic and Admitted groups (2.9±2.3 vs. 2.82±2.15; p=0.45). CONCLUSION A medical condition, such as a surgery, without proper assistance is unlikely to be enough for a patient to stop smoking for, at least, 24h prior to admission. The proximity of a surgery was not associated with smoking relapse 24h before the procedure.