Sebastião Araújo

Avaliação das pressões respiratórias máximas em pacientes renais crônicos nos momentos pré e pós-hemodiálise

INTRODUCTION AND OBJECTIVE: Maximal inspiratory and expiratory pressures (PImax and PEmax) are used to assess the integrity of respiratory muscles by measuring their strength. The aim of this study was to assess the immediate influence of hemodialysis (HD) on respiratory muscle strength by measuring PImax and PEmax, investigating the integrity of that musculature and/or the presence of muscular weakness. METHOD: A prospective, crosssectional study was carried out on a convenience sample of 35 patients with chronic kidney disease (26 men and 9 women; mean age, 51.7 ± 14.7 years) at the Nephrology Division of the Hospital Universitario Alzira Vellano, in the city of Alfenas, in the state of Minas Gerais, Brazil. Patients had their PImax and PEmax taken in the seated position (at 90°) by using a digital manovacuometer (MVD 300®) attached to a notebook for reading and recording data obtained before and after the HD session. RESULTS: Both PImax and PEmax were lower than the values predicted for pre- and post-HD (p < 0.0001). Comparing the values obtained pre-HD and post- HD, PImax showed a slight improvement (p = 0.0420), evidenced only in patients with pre-HD values below 60 cmH2O (Wilcoxon; p = 0.0480). Post-HD PEmax did not differ from the pre-HD measure (p = 0.4987). CONCLUSION: The CKD patients showed a serious impairment of their respiratory muscle function, and only one isolated HD session could not significantly improve their maximum respiratory pressures. A slight improvement in the inspiratory strength was observed in patients whose PImax was lower than 60 cm-H2O before the procedure.

Multiple organ failure in septic patients

Multiple organ failure (MOF) is the main cause of death in ICUs, especially affecting septic patients. It is strongly related to number of systems with failure, type of system involved, risk factors such as age, previous chronic diseases, delayed or inadequate resuscitation, persistent infection, immune suppression, and others. The prognoses is worse for patients rather than in elective or emergency surgical patients. The objective of this article is to provide data from our university teaching hospital ICU related to the incidence of septic patients, the distribution of MOF, and distribution of failure among each of the organs. The mortality rate, relationship between mortality and age, and mortality and types of organs affected were evaluated. The main bacterial causes of sepsis were also identified. A retrospective evaluation was done of 249 patients admitted to the ICU in a 4 month period during 1999. Fifty four patients had sepsis diagnosed by ACCS/SCCM criteria. There were 37 men and 17 women; 24 medical and 30 post-surgical patients (9 after elective surgery and 21 emergency patients). APACHE II score was calculated on admission and MOF, measured for the first five days, was diagnosed using Marshall and Meakins criteria. The statistical method used was non-parametric Mann-Whitney test, p<0.05 was considered significant. The incidence of sepsis was recorded in 54/249 patients (22%). Thirty of these 54 patients (56%) died. Death occurred in 2 of 11 patients with one organ failure (18%), in 14/27 with 2 or 3 organ failures (52%), and 14/16 with 4 or more organ failures (88%). None of the three patients 15 to 20 years old died, 17/32 (55%) patients age 21-60 years, and >61 years 13/19 (68%), died. There were 23 patients with positive bacterial culture. The most frequent bacteria found were: Pseudomonas aeruginosa (5), multiresistant Acinetobacter baumanii (3), Staphylococcus epidermidis (3), Enterobacter aerogenes (3), Klebsiella pneumoniae (2) and multiresistant Staphylococcus aureus (2). The mean value +/- SD of APACHE II (mortality risk) for survivors was 21 +/- 18 and for non-survivors 42 +/- 26 (p<0.001). We conclude that MOF due to sepsis in an ICU is frequent, with high mortality related to the number of failing organs, age and high APACHE II.

Theoretical knowledge of nurses working in non-hospital urgent and emergency care units concerning cardiopulmonary arrest and resuscitation

Non-Hospital Urgent and Emergency Care Units were created to deliver care to patients in chronic or acute situations and to coordinate the flow of urgent care. This descriptive study analyzed the theoretical knowledge of nurses working in these units concerning cardiopulmonary arrest and resuscitation. A questionnaire was applied to 73 nurses from 16 units in seven cities in the region of Campinas, SP, Brazil. The respondents displayed some gaps in their knowledge such as how to detect Cardiopulmonary Arrest (CPA), the ability to list the sequence of basic life support, and how to determine the appropriate compression to ventilation ratio (>60%). They also did not know: the immediate procedures to take after CPA detection (>70%); the rhythm pattern present in a CPA (>80%); and they only partially identified (100%) the medication used in cardiopulmonary resuscitation. The average score on a scale from zero to ten was 5.2 (± 1.4). The nurses presented partial knowledge of the guidelines available in the literature.As unidades nao hospitalares de atendimento a urgencia e emergencia foram criadas para atender pacientes com quadros agudos ou cronicos agudizados e ordenar os fluxos de urgencia. O objetivo deste estudo foi analisar o conhecimento teorico dos enfermeiros dessas unidades, sobre parada cardiorrespiratoria e ressuscitacao cardiopulmonar. Este e um estudo descritivo, cujos dados foram obtidos pela aplicacao de questionario a 73 enfermeiros de 16 unidades, de sete municipios da Regiao Metropolitana de Campinas. Observou-se que os entrevistados apresentaram lacunas de conhecimento sobre como detectar a parada cardiorrespiratoria, a sequencia do suporte basico de vida e a relacao ventilacao/compressao (>;60%); desconhecem as condutas imediatas apos deteccao (>;70%) e os padroes de ritmos presentes na parada cardiaca (>;80%) e que identificaram parcialmente (100%) os farmacos utilizados na ressuscitacao cardiopulmonar. A nota media foi 5,2 (±1,4), em uma escala de zero a dez. Conclui-se que os enfermeiros apresentaram conhecimento parcial das diretrizes disponiveis na literatura.

Edema pulmonar neurogênico: relato de dois casos

Neurogenic pulmonary edema is a rare and serious complication in patients with head injury. It also may develop after a variety of cerebral insults such as subarachnoid hemorrhage, brain tumors and after epileptic seizures. Thirty six patients with severe head injury and four patients with cerebrovascular insults treated in Intensive Care Unit of HC-UNICAMP from January to September 1995 were evaluated. In this period there were two patients with neurogenic pulmonary edema, one with head injury and other with intracerebral hemorrhage. Diagnosis was made by rapid onset of pulmonary edema, severe hypoxemia, decrease of pulmonary complacence and diffuse pulmonary infiltrations, without previous history of tracheal aspiration or any other risk factor for developement of adult respiratory distress syndrom. In the first case, with severe head trauma, neurogenic pulmonary edema was diagnosed at admission one hour after trauma, associated with severe systemic inflammatory reaction, and good outcome in three days. The second case, with hemorragic vascular insult, developed neurogenic pulmonary edema the fourth day after drenage of intracerebral hematom and died.

Fatores associados à maior mortalidade e tempo de internação prolongado em uma unidade de terapia intensiva de adultos.

OBJETIVO: A unidade de terapia intensiva e sinonimo de gravidade e apresenta taxa de mortalidade entre 5,4% e 33%. Com o aperfeicoamento de novas tecnologias, o paciente pode ser mantido por longo periodo nessa unidade, ocasionando altos custos financeiros, morais e psicologicos para todos os envolvidos. O objetivo do presente estudo foi avaliar os fatores associados a maior mortalidade e tempo de internacao prolongado em uma unidade de terapia intensiva adulto. METODOS: Participaram deste estudo todos os pacientes admitidos consecutivamente na unidade de terapia intensiva de adultos, clinica/cirurgica do Hospital das Clinicas da Universidade Estadual de Campinas, no periodo de seis meses. Foram coletados dados como: sexo, idade, diagnostico, antecedentes pessoais, APACHE II, dias de ventilacao mecânica invasiva, reintubacao orotraqueal, traqueostomia, dias de internacao na unidade de terapia intensiva, alta ou obito na unidade de terapia intensiva. RESULTADOS: Foram incluidos no estudo 401 pacientes, sendo 59,6% homens e 40,4% mulheres, com idade media de 53,8±18,0 anos. A media de internacao na unidade de terapia intensiva foi de 8,2±10,8 dias, com taxa de mortalidade de 13,46%. Dados significativos para mortalidade e tempo de internacao prolongado em unidade de terapia intensiva (p 11, traqueostomia e reintubacao. CONCLUSAO: APACHE >11, traqueostomia e reintubacao estiveram associados, neste estudo, a maior taxa de mortalidade e tempo de permanencia prolongado em unidade de terapia intensiva.

Syndromes related to sodium and arginine vasopressin alterations in post-operative neurosurgery

BACKGROUND Cerebral salt wasting syndrome (CSWS), syndrome of inappropriate antidiuretic hormone secretion (SIADH) and diabetes insipidus (DI) are frequently found in postoperative neurosurgery. PURPOSE To identify these syndromes following neurosurgery. METHOD The study included 30 patients who had been submitted to tumor resection and cerebral aneurysm clipping. Sodium levels in serum and urine and urine volume were measured daily up to the 5th day following surgery. Plasma arginine vasopressin (AVP) was measured on the first, third and fifth days post-surgery. RESULTS CSWS was found in 27/30 patients (90%), in 14 (46.7%) of whom it was associated with a reduction in the levels of plasma AVP (mix syndrome). SIADH was found in 3/30 patients (10%). There was no difference between the two groups of patients. CONCLUSION CSWS was the most common syndrome found, and in half the cases it was associated with DI. SIADH was the least frequent syndrome found.

Highlighting intracranial pressure monitoring in patients with severe acute brain trauma

Intracranial pressure (ICP) monitoring was carried out in 100 patients with severe acute brain trauma, primarily by means of a subarachnoid catheter. Statistical associations were evaluated between maximum ICP values and: 1) Glasgow Coma Scale (GCS) scores; 2) findings on computed tomography (CT) scans of the head; and 3) mortality. A significant association was found between low GCS scores (3 to 5) and high ICP levels, as well as between focal lesions on CT scans and elevated ICP. Mortality was significantly higher in patients with ICP > 40 mm Hg than in those with ICP < or = 20 mm Hg.

Influência da fisioterapia respiratória na pressão intracraniana em pacientes com traumatismo craniencefálico grave

OBJETIVO: Estudar a influencia das manobras de fisioterapia respiratoria na pressao intracraniana (PIC) dos pacientes com trauma craniencefalico grave. METODO: Trinta e cinco pacientes com trauma craniencefalico grave foram incluidos no estudo, sendo divididos em tres grupos: com PIC < 10, 11-20 e 21-30 mmHg. As variaveis monitorizadas foram: PIC e pressao arterial media. A pressao de perfusao cerebral foi calculada pela diferenca de pressao arterial media e PIC. RESULTADOS: A manobra de aspiracao traqueal causou aumento de PIC em todos os grupos. A pressao arterial media nao teve alteracoes e a pressao de perfusao cerebral diminuiu pouco, porem mantendo valores normais. CONCLUSAO: As manobras de fisioterapia respiratoria podem ser usadas com seguranca em pacientes com traumatismo craniencefalico grave, com PIC abaixo de 30 mmHg.Certo cuidado deve ser tomado durante a aspiracao traqueal.

Impact of alveolar recruitment maneuver in the postoperative period of videolaparoscopic bariatric surgery

BACKGROUND AND OBJECTIVES Pulmonary complications in bariatric surgery are common and, therefore, alveolar recruitment maneuvers (ARM) have been used to prevent or reduce them in the postoperative period (POP). The aim of this study was to evaluate the impact of ARM performed intraoperatively in patients undergoing bariatric surgery by videolaparoscopy in the incidence of postoperative pulmonary complications. METHODS Randomized clinical trial with 30 patients divided into control group (CG) and experimental group (EG), with analysis of spirometric, ventilatory, hemodynamic, and radiographic variables. ARM was performed in EG with positive end expiratory pressure of 30 cmH₂O and inspiratory plateau pressure of 45 cmH₂O for 2 minutes after pneumoperitoneum deflation. RESULTS We observed a significant decrease in spirometric values (p ≤ 0.001) and higher incidence of pulmonary complications on chest radiograph (p=0.02) in CG, as well as significant improvement in dyspnoea Borg scale (p ≤ 0.001) in EG. CONCLUSIONS We conclude that ARM is a safe and effective technique when used for prevention of pulmonary complications in patients undergoing bariatric surgery, resulting in more favorable radiological and spirometric findings in the experimental group compared to the control group in the PO.

Capacitação teórica do enfermeiro para o atendimento da parada cardiorrespiratória

A equipe de enfermagem frequentemente e quem testemunha a parada cardiorrespiratoria (PCR). Portanto, deve possuir conhecimentos suficientes para realizar os primeiros atendimentos. O sucesso da reanimacao cardiorrespiratoria (RCR) depende do tempo entre a ocorrencia e o inicio do tratamento, da harmonia e sincronismo da equipe e da capacitacao dos profissionais. Foram objetivos do estudo: elaborar um programa de capacitacao para enfermeiros na RCR, capacitar o enfermeiro para o atendimento da PCR, avaliar o conhecimento dos enfermeiros antes e apos sua participacao no programa e comparar a atuacao dos enfermeiros submetidos ao programa com os do grupo controle. O estudo foi desenvolvido em um hospital universitario e contemplou tres etapas: etapa-I, capacitacao teoricopratica; etapa-II, avaliacao recente do conhecimento teorico-pratico; e etapa-III, avaliacao tardia. A amostra foi composta por 21 enfermeiros no grupo-A (controle ? nao participou do programa de capacitacao) e 38 no grupo-B (experimental ? participou do programa). Os instrumentos teorico e pratico foram submetidos a validacao de conteudo e pre-teste. Na avaliacao dos juizes nao houve discordância significativa quanto a organizacao (p=0,368), objetividade (p=1,000), exceto quanto a clareza (p=0,042) para o instrumento-I (teorico). Em relacao ao instrumento-II (pratico), nao houve discordância em nenhum dos itens (p?0,05). Na analise de desempenho dos enfermeiros verificou-se que a media das notas da avaliacao teorica no grupo-A variou de forma progressiva nas tres etapas: 6,45, 6,66 e 7,10; e no grupo-B de forma oscilante: 6,48, 8,36 e 8,0, respectivamente, com diferenca estatisticamente significativa entre os grupos nas etapas II e III (p<0,001). Em relacao as atividades praticas do suporte basico de vida (SBV) e suporte avancado (SAV), no grupo-A as medias de notas foram 3,90 e 3,49 na etapa-II e 4,32 e 3,72 na etapa-III, respectivamente, enquanto no grupo-B obtiveram as medias de notas 6,92 e 5,66 na etapa-II e 7,08 e 4,99 na etapa-III, espectivamente. As diferencas entre os grupos nas duas etapas das duas atividades foram significativas (p<0,001). Conclui-se que os conteudos abordados e os instrumentos utilizados subsidiaram de forma favoravel a execucao e avaliacao do programa de capacitacao elaborado e implementado para os enfermeiros no atendimento da PCR. Observou-se melhora no desempenho tanto nas atividades teoricas quanto nas praticas. O grupo-B foi superior em ambos os desempenhos em relacao ao grupo-A. No entanto, o desempenho na atividade teorica do grupo-B apos uma semana foi superior ao de tres meses; ja na atividade pratica do SBV, o desempenho na etapa-III foi superior a etapa-II, enquanto no SAV o desempenho da etapa-III foi inferior ao da etapa-II. O comportamento do desempenho dos sujeitos do grupo-A diferiu tanto nas atividades teorica como na pratica em relacao ao grupo-B. Na avaliacao teorica observou-se uma melhora progressiva nas tres etapas, assim como nas duas etapas das atividades praticas de SBV e SAV. Diante destes resultados, acreditase que o programa de capacitacao elaborado podera ser amplamente utilizado na instituicao estudada e tambem adaptado para utilizacao em outras. AbOBJECTIVES OF THE STUDY to apply a theoretical qualification program for nurses in cardiopulmonary resuscitation and compare the theoretical knowledge group-A-control with group-B-experimental. This program comprised three stages: Stage-I, evaluation pre-theoretical qualification; Stages-II and III, evaluation of the recent (one week after stage-I) and later (three months after stage-I) qualification. The sample was composed of 21 nurses in Group-A and 38 in Group-B. The mean performance score in Group-A varied in a progressive form: 6.45; 6.66 and 7.10; in Group-B, in an oscillating form: 6.48; 8.36 and 8.0; stages II and III (p<0,001). It was concluded that: Group-B has been superior to Group-A. However, the performance of Group-B stage-II was superior to stage-III, while in the Group-A it was observed a gradual improvement.