Nutritional assessment of the critically ill patients with cardiac disease under renal replacement therapy: diagnostic difficulty

OBJETIVO: Realizar avaliação nutricional em pacientes cardiopatas críticos que necessitem de terapia de substituição renal. MÉTODOS: Pacientes cardiopatas críticos, internados em unidade de terapia intensiva, que apresentavam insuficiência renal com indicação de terapia de substituição renal foram submetidos à avaliação nutricional com a utilização de medidas antropométricas e análise laboratorial. RESULTADOS: Foram avaliados 43 pacientes, com idade de 64±15 anos, 26 do sexo masculino. A média da fração de ejeção do ventrículo esquerdo foi de 0,36±0,16. Avaliação do estado nutricional com base no índice de massa corpórea revelou 18 pacientes eutróficos, 6 pacientes com baixo peso, 19 pacientes com sobrepeso ou obesidade. Baseado na medida da prega cutânea tricipital, 16 pacientes eram eutróficos, 27 pacientes apresentaram algum grau de depleção e, com base na circunferência do braço e na circunferência muscular do braço, 41 pacientes apresentaram algum grau de depleção. Dados laboratoriais evidenciaram depleção grave baseado na albumina em 28 pacientes e 27 pacientes tinham depleção grave de acordo com a contagem de linfócitos. CONCLUSÃO: A desnutrição é comum em pacientes cardiopatas críticos em terapia de substituição renal. Avaliação nutricional baseada no índice de massa corpórea não revelou ser bom método para diagnóstico de distúrbios nutricionais nesta população. Há necessidade de complementar a avaliação nutricional para identificação de desnutrição e possibilitar introdução precoce de suporte nutricional adequado.OBJECTIVE: Evaluate the nutritional status of patients with cardiac disease and concomitant renal dysfunction requiring renal replacement therapy. METHODS: Patients with cardiac disease and renal failure receiving renal replacement therapy, admitted to an intensive care unit, were submitted to nutritional evaluation, by use of anthropometric measurements and laboratory data. RESULTS: We studied 43 patients, mean age 64±15 years, 26 were men. The mean left ventricular ejection fraction was 0.36±0.16. Analysis of anthropometric measurements, based on body mass index disclosed that, 18 patients were normal, 6 were underweight and 19 were overweight or obese. Based on measurement of triceps skinfold thickness, 16 patients were considered normal and 27 had some degree of depletion. Measurements of midarm circumference and midarm muscular circumference showed 41 patients with some degree of depletion. Laboratory data revealed 28 patients with depletion based on albumin levels and 27 with depletion based on lymphocyte count. CONCLUSIONS: Malnutrition is common in critically ill patients with cardiac disease and renal failure receiving renal replacement therapy. Nutritional assessment based on body mass index did not prove to be a good index for diagnosis of nutritional disorders. The nutritional evaluation must be complemented in order to identify malnutrition and introduce early nutritional support

Trichosporon asahii an emerging etiologic agent of fungal infection and colonization in heart failure patients in intensive care unit: case report and literature review

JUSTIFICATIVA E OBJETIVOS: As infecções fúngicas por Trichosporon Asahii têm sido cada vez mais freqüentes nas últimas duas décadas. Quadros graves com alta mortalidade são tradicionalmente descritos em pacientes neutropênicos com câncer. Recentemente, a infecção tem ocorrido também em outros grupos de pacientes. O objetivo deste estudo foi descrever a crescente prevalência de Trichosporon asahii em unidade de terapia intensiva cardiológica (UTIC), com perfil de pacientes habitualmente não susceptíveis a tal infecção fúngica, relatar um caso clínico e revisão da literatura. RELATO DO CASO: Paciente do sexo feminino, 85 anos, com antecedentes de hipertensão arterial sistêmica, insuficiência cardíaca (fração de ejeção = 30%) e embolia pulmonar, admitida na UTI depois de parada cardiorrespiratória em fibrilação ventricular durante consulta de rotina. Evoluiu sem seqüela neurológica. O ecocardiograma não revelou alterações em relação ao exame anterior. Não houve alteração dos indicadores de necrose miocárdica. A paciente apresentou falha na extubação traqueal e desmame difícil, necessitando ventilação mecânica prolongada mesmo após traqueostomia. Houve complicações por insuficiência renal aguda e infecções recorrentes (respiratória, urinária e sistêmica), com boa resposta ao tratamento com antibióticos de amplo espectro. Após sete meses de internação na UTI, evoluiu com choque séptico, associado à infecção urinária por Trichosporon asahii, com hemoculturas identificadas pelo mesmo fungo. Iniciado tratamento com anfotericina B lipossomal (5 mg/kg/dia). Apesar do uso associado de vancomicina e imipenem, houve piora clínica progressiva. Hemoculturas colhidas no sétimo dia de uso de antifúngico revelaram-se negativas, porém a urocultura ainda revelou o crescimento de T. asahii. Evoluiu com óbito após 18 dias de tratamento, por falência de múltiplos órgãos. CONCLUSÕES: O aumento da gravidade dos pacientes internados nas UTI e o uso disseminado de antibióticos de amplo espectro têm possibilitado o surgimento de infecções por fungos incomuns. As infecções graves por Trichosporon asahii, descritas como restritas a pacientes imunossuprimidos, oncológicos e hematológicos, têm sido freqüentemente encontradas em pacientes idosos, com insuficiência cardíaca grave e com alta mortalidade intra-hospitalar, internados em UTI. Deve-se estar atento à possibilidade da emergência de infecções por fungos não usuais em pacientes com este perfil clínico.BACKGROUND AND OBJECTIVES: Infection with the non-Candida yeast species Trichosporon have been recognized with increasing frequency over the last two decades. Invasive disease due to trichosporonosis has been reported from neutropenic patients with cancer and the mortality is high. Recently, others groups of patients have become susceptible to this rare fungi. We report the emerging of infection with pathogenic Trichosporon asahii in severely ill heart failure patients in a tertiary cardiological intensive care unit (CICU). We describe our data, and report a fatal case of disseminated trichosporonosis in a patient with heart failure. We also review literature pertaining to T. asahii infections. CASE REPORT: An 85 year-old woman with a history of hypertension, heart failure (ejection fraction (EJ): 30%) and pulmonary embolism was admitted to a medical cardiological ICU after cardiac arrest (ventricular fibrillation) resuscitated during a routine consultation. There were no neurological sequelae and the echocardiogram revels no changes, neither the cardiac biomarkers. Ventricular fibrillation was considered secondary to heart failure. The patient had extubation failure and difficult weaning needing long term mechanical ventilation even after tracheostomy. Her hospital course was complicated by acute renal failure and recurrent respiratory, urinary and systemic bacterial infections, which responded to broad-spectrum antibiotics. After a temporary improvement she developed urinary infection and subsequent septic shock. Cultures of urine and blood specimens grew T. asahii. Treatment with liposome amphotericin B (5 mg/kg/day) was started. Despite receiving vancomycin and imipenem, the clinical condition of the patient deteriorates. Blood taken for culture on the seventh day of amphotericin B therapy were negative but urine specimen still grew T. asahii. On the eighteenth day of antifungal therapy, the patient died with multiorgan failure. CONCLUSIONS: The increasing of severely ill patients, and the use of broad spectrum antibiotics, has predisposed the emerging of invasive infections by rare and new opportunistic fungal pathogens. Severe infection related to T. asahii, until recently restricted to neutropenic patients with cancer, has been frequently identified in heart failure patients with advanced age. The mortality is high. These data highlights the importance of considering this group of patients as a risk group for T. asahii infection

Dilated cardiomyopathy in a case of Shwachman-Diamond syndrome

The Shwachman-Diamond syndrome is an autosomal recessive bone marrow failure syndrome with exocrine pancreatic insufficiency. Additional organ systems, such as the liver, heart and bone, may also be affected. We report a patient with a long history of cardiac failure and diagnosis of dilated cardiomyopathy with intermittent neutropenia. Periodic follow-up revealed progressive cardiac failure and pulmonary hypertension. A diagnosis of Shwachman-Diamond syndrome was made at the autopsy

Arterial distensibility as a possible compensatory mechanism in chronic aortic regurgitation

OBJECTIVE: To evaluate elastic properties of conduit arteries in asymptomatic patients who have severe chronic aortic regurgitation. METHODS: Twelve healthy volunteers aged 30±1 years (control group) and 14 asymptomatic patients with severe aortic regurgitation aged 29±2 years and left ventricular ejection fraction of 0.61±0.02 (radioisotope ventriculography) were studied. High-resolution ultrasonography was performed to measure the systolic and diastolic diameters of the common carotid artery. Simultaneous measurement of blood pressure enabled the calculation of arterial compliance and distensibility. RESULTS: No differences were observed between patients with aortic regurgitation and the control group concerning age, sex, body surface, and mean blood pressure. Pulse pressure was significantly higher in the aortic regurgitation group compared with that in the control group (78±3 versus 48±1mmHg, P<0.01). Arterial compliance and distensibility were significantly greater in the aortic regurgitation group compared with that in the control group (11.0±0.8 versus 8.1±0.7 10-10 N-1 m4, P=0.01 e and 39.3±2.6 versus 31.1±2.0 10-6 N-1 m², P=0.02, respectively). CONCLUSION: Patients with chronic aortic regurgitation have increased arterial distensibility. Greater vascular compliance, to lessen the impact of systolic volume ejected into conduit arteries, represents a compensatory mechanism in left ventricular and arterial system coupling

Exercício resistido na avaliação da disfunção endotelial na insuficiência cardíaca Resistive exercise in the evaluation of endothelial dysfunction in heart failure

OBJETIVO: Avaliar o uso de exercício físico resistido no estudo da disfunção endotelial na insuficiência cardíaca comparativamente à hiperemia reativa (HR). MÉTODOS: Dezoito portadores de insuficiência cardíaca (IC) e 15 voluntários realizaram esforço físico manual de preensão intermitente em bolsa pneumática com intensidade correspondente a 75% da carga máxima previamente avaliada. Foram avaliados por ultra-sonografia vascular de alta resolução para análise dos diâmetros da artéria braquial e fluxos bem como determinação do débito cardíaco em repouso, após HR e após exercício. Foram calculados o índice de fluxo sistólico na artéria braquial e o índice cardíaco. RESULTADOS: Houve aumento do índice de fluxo sistólico na artéria braquial nas condições HR e exercício físico sendo maior nessa última. Houve aumento do índice cardíaco nas condições de estudo comparativamente ao repouso. CONCLUSÃO: O exercício físico resistido, na carga avaliada, aumenta o fluxo sanguíneo local de forma mais intensa que a HR, constituindo-se numa opção fisiológica à avaliação da disfunção endotelial na IC .<br>OBJECTIVE: To evaluate the use of resistive exercise in the study of endothelial dysfunction in heart failure (HF) comparatively to reactive hyperemia (RH). METHODS: Eighteen patients with heart failure and 15 normal volunteers were submitted to intermittent handgrip exercise in a pneumatic bag, at an intensity that corresponds to 75% of the previously assessed maximum load. Patients underwent high-resolution vascular ultrasonography for brachial artery diameter and flow evaluation as well as cardiac output determination at rest, RH and after exercise. The systolic flow index in the brachial artery and cardiac index were calculated. RESULTS: Systolic flow index increase in the brachial artery was observed after RH and physical exercise, with the latter presenting the highest increase. There was an increase in the cardiac index after the study conditions in comparison to resting conditions. CONCLUSION: Resistive exercise, performed at the assessed load, increases blood flow more intensively than RH, constituting a physiological option for the evaluation of endothelial function in HF