Proposta de abolição do teste de sensibilidade cutâneo antes da aplicação do soro anti-rábico de origem eqüina

An epizootic outbreak of rabies occurred in 1995 in Ribeirão Preto, SP, with 58 cases of animal rabies (54 dogs, 3 cats and 1 bat) confirmed by the Pasteur Institute of São Paulo, and one human death. The need to provide care to a large number of people for the application of equine rabies immune globulin (ERIG) prevented the execution of the skin sensitivity test (SST) and often also the execution of desensitization, procedures routinely used up to that time at the Emergency Unit of the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (EU-UHFMRP-USP), a reference hospital for the application of heterologous sera. In view of our positive experience of several years with the abolition of SST and of the use of premedication before the application of antivenom sera, we used a similar schedule for ERIG application. Of the 1489 victims of animal bites, 1054 (71%) received ERIG; no patient was submitted to SST and all received intravenously anti-histamines (anti-H1 + anti-H2) and corticosteroids before the procedure. The patients were kept under observation for 60 to 180 minutes and no adverse reaction was observed. On the basis of these results, since December 1995 ERIG application has been decentralized in Ribeirão Preto and has become the responsibility of the Emergency Unit of the University Hospital and the Central Basic Health Unit, where the same routine is used. Since then, 4216 patients have received ERIG (1818 at the Basic Health Unit and 2398 at the EU-UHFMRP), with no problems. The ideal would be the routine use of human rabies immune globulin (HRIG) in public health programs, but this is problematic, because of their high cost. However, while this does not occur, the use of SST is no longer justified at the time of application of ERIG, in view of the clinical evidence of low predictive value and low sensitivity of SST involving the application of heterologous sera. It is very important to point out that a negative SST result may lead the health team to a feeling of false safety that no adverse reaction will occur, but this is not true for the anaphylactoid reactions. The decision to use premedication, which is based on knowledge about anaphylaxis and on the pharmacology of the medication used, is left to the judgment of health professionals, who should always be prepared for eventual untoward events.Durante o ano de 1995, ocorreu em Ribeirão Preto, SP, uma epizootia de raiva, com 58 casos de raiva animal (54 cães, 3 gatos, 1 morcego), confirmados pelo Instituto Pasteur, S. Paulo, e um óbito humano. A necessidade de prestar atendimento a um grande número de pessoas para aplicação do soro anti-rábico eqüino, tornou inviável a realização do teste de sensibilidade intradérmico (TSI) e da dessensibilização, utilizados até então como rotina, conforme orientação da Organização Mundial da Saúde e do Ministério da Saúde, na Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, hospital de referência para aplicação de soros heterólogos. Com base na experiência positiva de vários anos com a abolição do TSI e uso de pré-medicação antes da aplicação endovenosa de soros antivenenos, foi utilizado esquema semelhante para a aplicação de soro anti-rábico eqüino (SARE). Das 1489 vítimas de mordeduras de animais, 1054 (71%) receberam SARE; nenhuma delas foi submetida ao TSI e todas receberam previamente anti-histamínicos (anti-H1 + anti-H2) e corticosteróides por via intravenosa, permanecendo em observação durante 60 a 180 minutos, não sendo verificada nenhuma reação adversa. A partir desses resultados, desde dezembro de 1995 a aplicação do SARE foi descentralizada em Ribeirão Preto, ficando responsável a Unidade Básica de Saúde Central (UBDS) pelos pacientes moradores da cidade de Ribeirão Preto, e a Unidade de Emergência do Hospital das Clínicas, pelos provenientes das cidades componentes da macroregião, utilizando-se a mesma rotina nesses dois locais, ou seja, abolição do TSI e uso de pré-medicação. Desde então até dezembro de 1999, 4216 pacientes receberam SARE, sem problemas (2398 na UE-HCFMRP e 1818 na UBDS). O ideal seria a possibilidade de utilização de imunoglobulina anti-rábica humana nos programas de saúde pública, o que é problemático devido ao seu alto custo. Enquanto isso não ocorrer, a realização de TSI quando da aplicação de SARE não mais se justifica, devido às evidências do baixo valor preditivo e baixa sensibilidade dos TSI frente à aplicação de soros heterólogos. Mais importante ainda, um TSI negativo pode dar ao profissional de saúde a falsa segurança de que não ocorrerá nenhuma reação, o que não é válido para as reações anafilactóides. A decisão da utilização de pré-medicação, que se baseia no conhecimento da fisiopatologia da anafilaxia e na farmacologia da medicação utilizada, fica a critério do profissional de saúde, que deve sempre estar preparado para eventuais intercorrências

Acidentes por animais peçonhentos: serpentes peçonhentas

São abordados aspectos da fisiopatologia, clínica e terapêutica dos envenenamentos humanos, causados por serpentes peçonhentas dos gêneros Bothrops, Crotalus e Micrurus, que ocorrem no sudeste do Brasil. Elaboração de diretrizes para o atendimento dos pacientes na U.E-HCFMRP-USP e reprodução dos princípios para a indicação de soroterapia antiveneno (SAV). Quando aplicada, a SAV deverá ser administrada por via intravenosa, gota a gota, sem diluição, precedida por drogas anti-histamínicas (anti H 1 e anti H2) e corticóides, visando à proteção contra possíveis reações de hipersensibilidade e sem que sejam realizados testes cutâneos previamente.    Physiopathological, clinical and therapeutic aspects of human envenomation caused by Bothrops, Crotalus and Micrurus gender of poisonous snakes, prevalent in the southwest brazilian region, are discussed. The U.E.-HCFMRP-USP guidelines for treatment and the indications for antivenom serum are shown. If indicated, the antivenom serum should be given through intravenous infusion, drop by drop, after antihistaminic (anti H 1 and anti H2) and corticoids usage, to prevent possible hipersensibility reaction. No cutaneous sensibility test is advocated previously to the antivenom serum.   &nbsp

Envenomation caused by poisonous animals: scorpions and spiders

São abordados aspectos da fisiopatologia, clínica e terapêutica dos envenenamentos humanos, causados por escorpiões do gênero Tityus e aranhas do gêneros Phoneutria e Loxosceles, encaminhados ao Centro de Controle de Intoxicações (CCI) da U.E.-HCFMRPUSP. Quando indicada, a soroterapia antiveneno (SAV) específica deverá obedecer ao roteiro de aplicação, descrito para os acidentes ofídicos.Physiopathological, clinical and therapeutic aspects of human envenomation directed to the Center for Control of Intoxication of the U.E. – HCFMRP-USP, caused by Tityus gender scorpions and Phoneutria and Loxosceles gender spiders are discussed. Specific antivenom serum should be employed, if indicated, according to the principles described to the poisonous snakes

Impact of children with complex chronic conditions on costs in a tertiary referral hospital

OBJECTIVES To investigate the impact of complex chronic conditions on the use of healthcare resources and hospitalization costs in a pediatric ward of a public tertiary referral university hospital in Brazil. METHODS This is a longitudinal study with retrospective data collection. Overall, three one-year periods, separated by five-year intervals (2006, 2011, and 2016), were evaluated. Hospital costs were calculated in three systematic samples of 100 patients each, consisting of patients with and without complex chronic conditions in proportion to their participation in the studied year. RESULTS Over the studied period, the hospital received 2,372 admissions from 2,172 patients. The proportion of hospitalized patients with complex chronic conditions increased from 13.3% in 2006 to 16.9% in 2016 as a result of a greater proportion of neurologically impaired children, which rose from 6.6% to 11.6% of the total number of patients in the same period. Patients’ complexity also progressively increased, which greatly impacted the use of healthcare resources and costs, increasing by 11.6% from 2006 (R$1,300,879.20) to 2011 (R$1,452,359.71) and 9.4% from 2011 to 2016 (R$1,589,457.95). CONCLUSIONS Hospitalizations of pediatric patients with complex chronic conditions increased from 2006 to 2016 in a Brazilian tertiary referral university hospital, associated with an important impact on hospital costs. Policies to reduce these costs in Brazil are greatly needed

Body packing by rectal insertion of cocaine packets: a case report

Background: Body packing is used for international drug transport, immediate drug concealment during a police\ud searching or introducing drugs inside prisons. Despite the high level of specialization of dealers who have started\ud to manufacture more complex packs, up to 5% of patients could develop intoxication due to pack rupture. Bowel\ud obstruction is another acute complication.\ud Case presentation: A 27-year-old black male patient was sent to the hospital by court order for clinical evaluation\ud and toxicological examination. The patient was conscious, oriented, had good color, normal arterial pressure and\ud heart rate, and no signs of acute intoxication. Abdominal examination revealed discrete pain upon deep palpation\ud and a small mass in the left iliac fossa. A plain abdominal radiograph revealed several oval structures located in the\ud rectum and sigmoid. Fasting and a 50 g dose of activated charcoal every six hours were prescribed. After three\ud days, the patient spontaneously evacuated 28 cocaine packs.\ud Conclusion: Adequate clinical management and prompt identification of potential complications are of\ud fundamental importance in dealing with body packing

Parenteral nutrition support: prescriptions and follow up

The introduction of total parenteral nutrition support in the therapy of hospitalized patients has necessitated the development of a rig guidelines lo promote coast containment and optimal patient care. It is very kwon nowadays the impact of nutrition support team, which members include one or more physicians, nurses and pharmacists upon this practice, such as, the potential benefits derived from a particular mode of providing specifics parenteral feeding formulations and high performance in the assessment of nutrient intake of the hospitalized patient. The main purpose of this study is to present the Total Parenteral Nutrition Committee of the Clinics Hospital of Ribeirão Preto’s report concerning the specific parenteral feeding formulations to be used in the hospitalized patient.O suporte nutricional, na terapêutica de pacientes hospitalizados, requer o desenvolvimento de princípios que determinarão a melhor assistência nutricional, associada ao menor custo do procedimento. Reconhece-se, atualmente, o impacto causado pela formação de equipes ou comissões multidisciplinares de suporte nutricional parenteral, formadas por médicos, enfermeiros e farmacêuticos, sobre a racionalização da terapêutica nutricional, como a escolha de nutrientes específicos e a padronização das formulações nutritivas. O objetivo deste trabalho se relaciona com o uso de nutrição parenteral total, no Hospital das Clínicas de Ribeirão Preto, incluindo indicações, formulações, efeitos colaterais e benefícios. Paralelamente, é apresentada a padronização das formulações nutritivas parenterais, efetuada pela Comissão de Nutrição Parenteral do Hospital das Clínicas de Ribeirão Preto, a ser utilizada nos pacientes hospitalizados, que necessitem de terapia nutricional parenteral

Case Report Sustained Ventricular Tachycardia and Cardiogenic Shock due to Scorpion Envenomation

We describe a case of severe scorpion envenomation in an adult patient, with the presence of very rapid sustained ventricular tachycardia followed by cardiogenic shock, which was reversed by scorpion antivenom administration. Scorpion venom causes cardiac changes that can lead to an environment favoring arrhythmogenesis

Clinical update on scorpion envenoming

Abstract: Scorpion stings are currently the leading cause of venom-related injury to humans in Brazil and are a significant public health problem globally. Only scorpions of the Tityus genus are of medical importance in Brazil, and Tityus serrulatus is responsible for the most serious envenomations and deaths. The toxic effects of scorpion envenomation are due to a massive release of sympathetic and parasympathetic neurotransmitters; the severity is related to cardiac and hemodynamic changes, with cardiogenic shock and pulmonary edema contributing to the main causes of death. The pathophysiology of cardiac involvement has been discussed for decades and has been attributed to adrenergic discharge and a possible toxic effect of venom on the myocardium, while acute pulmonary edema may have a cardiogenic and/or non-cardiogenic origin. Currently, the clinical data point to catecholamine excess as the cause for reversible scorpion cardiomyopathy . These data include electrocardiographic changes, profiling of cardiac enzymes and troponin I, echocardiographic data with global or regional left ventricle dysfunction, and myocardial perfusion alterations compatible with spasm in the coronary microcirculation. Furthermore, recent data on cardiac magnetic resonance imaging findings, which are similar to those observed for stress-induced cardiomyopathy, have also been linked to catecholamine excess. The efficiency of antivenom serum treatment is controversial in the literature. Our experience in Brazil is that the management of patients with systemic manifestations of scorpion stings is based on three approaches, all of which are extremely important. These include symptomatic treatment, antivenom serum, and cardiorespiratory support