Clinical relevancy and risks of potential drug–drug interactions in intensive therapy

AbstractPurposeEvaluate the potential Drug–Drug Interactions (pDDI) found in prescription orders of adult Intensive Care Unit (ICU) of a Brazilian public health system hospital; quantify and qualify the pDDI regarding their severity and risks to the critical patient, using the database from Micromedex®.MethodsProspective study (January–December of 2011) collecting and evaluating 369 prescription orders (convenient sampling), one per patient.ResultsDuring the study 1844 pDDIs were identified and distributed in 405 pairs (medication A×medication B combination). There was an average of 5.00±5.06 pDDIs per prescription order, the most prevalent being moderate and important interactions, present in 74% and 67% of prescription orders, respectively. In total, there were 9 contraindicated, 129 important and 204 moderate pDDIs. Among them 52 had as management recommendation to “avoid concomitant use” or “suspension of medication”, while 306 had as recommendation “continuous and adequate monitoring”.ConclusionThe high number of pDDIs found in the study combined with the evaluation of the clinical relevancy of the most frequent pDDIs in the ICU shows that moderate and important interactions are highly incident. As the majority of them demand monitoring and adequate management, being aware of these interactions is major information for the safe and individualized risk management

Prevalence of potential drug-drug interactions in the intensive care unit of a Brazilian teaching hospital

Patients in intensive care unit are prescribed large numbers of drugs, highlighting the need to study potential Drug-Drug Interactions in this environment. The aim of this study was to delineate the prevalence and risk of potential drug-drug interactions between medications administered to patients in an ICU. This cross-sectional observational study was conducted during 12 months, in an adult ICU of a teaching hospital. Inclusion criteria were: prescriptions with 2 or more drugs of patients admitted to the ICU for >; 24 hours and age of ≥18 years. Potential Drug-Drug Interactions were quantified and classified through MicromedexTM database. The 369 prescriptions included in this study had 205 different drugs, with an average of 13.04 ± 4.26 (mean ± standard deviation) drugs per prescription. Potential Drug-Drug Interactions were identified in 89% of these, with an average of 5.00 ± 5.06 interactions per prescription. Of the 405 different pairs of potentially interacting drugs identified, moderate and major interactions were present in 74% and 67% of prescriptions, respectively. The most prevalent interaction was between dipyrone and enoxaparin (35.8%), though its clinical occurrence was not observed in this study. The number of potential Drug-Drug Interactions showed significant positive correlations with the length of stay in the intensive care unit, and with the number of prescribed drugs. Acknowledging the high potential for Drug-Drug Interactions in the ICU represents an important step toward improving patient safety and best therapy results

Death concepts and brain death diagnostic criteria

The authors present considerations about death and brain death concepts, as well the legal aspects for its diagnosis in Brazil. They also present the UNICAMP Protocol for the Diagnosis of Brain Death, revised and according with the current law, with standard techniques for the diagnostic exam. They emphasize the importance of a mature ethical position for this frequent and challenging situation.Os autores apresentam considerações a respeito dos conceitos de morte e morte encefálica, bem como dos aspectos legais para o seu diagnóstico no Brasil. Apresentam também o Protocolo para Diagnóstico de Morte Encefálica atualmente em vigor no Hospital das Clínicas da Universidade Estadual de Campinas, revisto e atualizado conforme a lei vigente no país, com a padronização técnica dos testes diagnósticos, ressaltando a importância de um posicionamento ético maduro frente a essa desafiante e cada vez mais frequente situação.70571

Fator natriurético atrial: ele é o responsável pela hiponatremia e natriurese em neurocirurgia?

To evaluate the presence of hyponatremia and natriuresis and their association with atrial natriuretic factor in neurosurgery patients. Methods: The study included 30 patients who had been submitted to intracranial tumor resection and cerebral aneurism clipping. Both plasma and urinary sodium and plasma atrial natriuretic factor were measured during the preoperative and postoperative time periods. Results: Hyponatremia was present in 63.33% of the patients, particularly on the first postoperative day. Natriuresis was present in 93.33% of the patients, particularly on the second postoperative day. Plasma atrial natriuretic factor was increased in 92.60% of the patients in at least one of the postoperative days; however, there was no statistically significant association between the atrial natriuretic factor and plasma sodium and between the atrial natriuretic factor and urinary sodium. Conclusion: Hyponatremia and natriuresis were present in most patients after neurosurgery; however, the atrial natriuretic factor cannot be considered to be directly responsible for these alterations in neurosurgery patients. Other natriuretic factors are likely to be involved282154160FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULO - FAPESP00/05990-9Avaliar a presença de hiponatremia e natriurese, bem como suas associações com o fator natriurético atrial em pacientes de neurocirurgia. Métodos: Foram incluídos 30 pacientes submetidos à ressecção de tumor intracraniano e à clipagem de aneurisma cerebral. Os níveis plasmáticos e urinários de fator natriurético atrial foram medidos durante os períodos pré e pós-operatório. Resultados: Hiponatremia esteve presente em 63,33% dos pacientes, particularmente no primeiro dia pós-operatório. Observou-se natriurese em 93,33% dos pacientes, principalmente no segundo dia pós-operatório. Os níveis plasmáticos de fator natriurético atrial estavam aumentados em 92,60% dos pacientes em pelo menos um dos dias pós-operatórios, mas não houve associação estatisticamente significante entre fator natriurético atrial e sódio plasmático, e entre fator natriurético atrial e sódio urinário. Conclusão: Após neurocirurgia, na maior parte dos pacientes, estiveram presentes hiponatremia e natriurese; contudo, o fator natriurético atrial não pôde ser considerado diretamente responsável por tais alterações nos pacientes neurocirúrgicos. Provavelmente, há o envolvimento de outros fatores natriurético

[thrombolysis In Massive Pulmonary Embolism Based On The Volumetric Capnography].

This is the first report of a patient submitted to chemical thrombolysis due to massive pulmonary embolism (PE) during the postoperative period of neurosurgery, in whom due to the lack of adequate clinical conditions, no imaging assessment was performed. Clinical, gasometric and capnographic data allowed the decision to perform the thrombolysis with safety. The P(a-et)CO2 gradient decreased from 46.4 mmHg to 11.8 mmHg (normal < 5 mmHg) and the end-tidal alveolar dead space fraction decreased from 0.85 to 0.37 (normal < 0.15) from the pre-thrombolysis period to the 7th day post-thrombolysis. We conclude that the volumetric capnography (VC) was useful in the patient's diagnosis and clinical follow-up.95e97-e9

Hemometabolismo cerebral : variações na fase aguda do coma traumatico

Orientador: Elizabeth M. A. B. QuagliatoTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Neste trabalho desenvolvemos o estudo de 27 pacientes .adulto.s com traumatismo craniencefálico grave, com 3 a 8 pontos na escala de coma de Glasgow (ECG), avaliados prospectivamente segundo um protocolo cumulativo padronizado para tratamento da hipertensão intracraniana aguda. Este protocolo incluía medidas da pressão intracraniana{pIC) e da extração cerebral de oxigênio_{EC02) -como se segue: PIC ou = 20 -mmHg - -Cabeceira elevada a 30 graus, hiperventilação mantendo os valores da EC02 entre 24% e 42%, manitol 20% em infusão intravenosa rápida (0,5 a 19/kg/dose)-e, caso os valores da PIC não correspondessem ao tratamento anterior, o item seguinte seria terapia barbitúrica (2 a 4 mg/kg/hora) e, por último, cirurgia descompressiva. Analisamos as inter-relações hemometabólicas envolvendo: pressão arterial média (P AM), pressão intracraniana (PIC), pressão parcial de gás carbônico PAC02), extração cerebral de oxigênio (EC02,) pressão de perfusão cerebral (PPC), diferença artério-jugular do conteúdo de oxigênio (DAV02) e extração sistêmica de oxigênio (ES02). Concluímos que: 1) A EC02 está altamente relacionada com diferentes níveis de PaC02; 2) a PPC não se correlaciona com a EC02 ¿em quaisquer níveis de PIC;3) a EC02 e a PIC estão diretamente relacionadas durante a fase aguda de hipertensão intracraniana, sugerindo um importante papel da hemodinâmica cerebral, em relação aos problemas da pressão intracraniana; 4) durante a hiperventilação otimizada, existe um acoplamento entre EC02 e a ES02Abstract: Twenty-seven adult patients with severe acute brain trauma, presenting with 3 to 8 points on the Glasgow Coma Scale, were prospectively evaluated according to a cumulative protocol for the management of acute intracranial hypertension, where intracranial pressure (ICP) and cerebral extraction of oxigen (CEOz) were measured and managed as follows: ICP 20 mmHg- head tilt at 30 degrees, hyperventilation maintaining the CEOz in the 24% - 42% range, 20% manitol fast intravenous infusion (0.5 - 1 / kg/dose). If adequate ICP control below 20 mmHg was not achieved, barbiturate therapy (2 - 4mg/kg/hour) and even decompressive surgery were adopted. We then analyzed hemometabolic interrelationships involving: mean arterial pressure (MAP), ICP, PACO2, CEO2, cerebral perfusion pressure (CPP),arterio- jugular oxygen content difference (A VDO2) and systemic extraction of oxygen (SEO2). We concluded that: 1) CEO2 and PACO2 are closely related; 2) CPP and CEO2 are unrelated; 3) CEO2 and ICP are closely related in acute intracranial hypertension, suggesting 4 relevant role of cerebral hemodynamics in relation to lCP problems; 4) during optimized hyperventilation, CEO2 and SEO2 are coupled.DoutoradoNeurocienciasDoutor em Fisiopatologia Medic