Homocysteine, von Willebrand factor and lipids in albino rats with diabetes mellitus streptozotocin

Objetivos: Estudar em ratos albinos portadores de diabetes melito induzido por estreptozotocina: 1. Valores plasmáticos de homocisteína. 2. Concentrações plasmáticas de fator von Willlebrand. 3. Valores séricos de colesterol total e frações e triglicérides. 4. Possíveis correlações entre valores plasmáticos de homocisteína, fator von Willebrand, colesterol total e frações e triglicérides. Métodos: 35 ratos (rattus norvegicus albinus), machos, adultos (peso 180-200g), com glicemias aferidas foram randomizados em três grupos: 1. Controle (n=10) - não receberam droga ou veículo; 2. “Sham” (n=10) - receberam solução (tampão citrato 0.1M, pH4.5) veículo da estreptozotocina e 3. Diabetes (n=15) - receberam estreptozotocina (Sigma® ) para indução do diabetes melito (60 mg/kg de peso) em dose única; via intraperitoneal, diluída em 0.3mL de solução veículo. Foram considerados diabéticos todos os ratos cujos valores de glicemia foram iguais ou superiores a 250mg/dL. Após 08 semanas de indução do diabetes melito os ratos foram pesados, as glicemias aferidas e anestesiados com ionembutal (Sigma® ) via intraperitoneal (50mg/kg peso). Colheu-se sangue da artéria aorta abdominal para determinação dos valores de homocisteína plasmática total seguindo metodologia descrita, através de ensaio HPLC (Shimadzu® ). O sangue restante foi centrifugado e o soro e o plasma aliquotados e congelados até determinação do fator von Willebrand (técnica de ELISA) e concentrações séricas de glicose de jejum final, colesterol total e frações HDL-, LDL- e VLDL-colesterol, triglicérides e creatinina. Os resultados foram expressos em média + desvio padrão. Para análise estatística utilizou-se a análise de variância (ANOVA), seguido do teste de comparações múltiplas de Tukey e quando necessário o teste Brown Forsythe, seguido do procedimento de comparações múltiplas de Dunnett. Para a construção dos diagramas de dispersão das variáveis calculou-se os coeficientes de correlação de Pearson. Resultados: O modelo foi reprodutível em 100% dos animais. A média dos valores de glicemia inicial foi: 88,7±5,9mg/dL (controle); 88,9±8,2mg/dL (“sham”) e 85,1±5,2mg/dL (diabetes). Através da ANOVA não houve diferença das médias de glicemia inicial entre os grupos (p=0,24). A média da glicemia final foi: 85,0±7,1mg/dL (controle); 80,9±5,0mg/dL (”sham”) e 353,5±98,2mg/dL (diabetes). Houve diferença estatisticamente significante entre o grupo diabetes e os demais (p<0,01). A média das concentrações plasmáticas de homocisteína foi: 7,9±2,3µmol/L (controle); 8,6±2,2µmol/L (“sham”) e 6,1±1,3µmol/L (diabetes), com diferença entre os grupos (p<0,01). A média dos valores do fator von Willebrand foi 0,15±0,3U/L (controle), 0,16±0,2U/L (“sham”) e 0,18±0,4U/L (diabetes), com diferença entre os grupos (p<0,05). Os valores de colesterol total tiveram médias de: 123,9±40,8mg/dL (controle); 107,0±38,6mg/dL (“sham”) e 87,5±5,9mg/dL (diabetes). A ANOVA mostrou diferença entre os grupos (p<0,05). No grupo diabetes houve correlação inversa entre glicemia final e ganho de peso, homocisteína e colesterol total, homocisteína e fração VLDL-colesterol e homocisteína e triglicérides. Conclusões: Neste estudo, utilizando como modelo biológico o diabetes melito induzido por estreptozotocina em ratos albinos, nas condições de experimento apresentadas, torna-se lícito concluir: 1. Os ratos diabéticos apresentaram valores menores de homocisteína. 2. O grupo diabetes apresentou valores maiores de fator von Willebrand. 3. Houve correlação inversa entre homocisteína e colesterol total, homocisteína e fração VLDL-colesterol e homocisteína e triglicérides. 4. Não houve correlação entre glicemia final e homocisteína, glicemia final e fator von Willebrand e homocisteína e fator von Willebrand nos ratos diabéticos. 5. Houve correlação inversa entre ganho de peso e glicemia final nos ratos diabéticos.Purpose: To determine plasma levels of homocysteine, von Willebrand factor, triglycerides and total cholesterol and fractions, in rats with diabetes induced by streptozotocin and evaluate possible correlations among these parameters. Methods: Adult male norvegicus albino rats (n=35), weigh (180-200g) were randomized into three groups: treated group (n=15), with diabetes induced by streptozotocin; sham group (n=10), treated with saline solution and normal control group (n=10), no treated. Initial fasting glucose was determinated before diabetes induction. Diabetes was induced by a single bolus intraperitoneal injection of streptozotocin, 60mg/kg/dose, diluted in citrate buffer (0.1M, pH4.5). Diabetes was confirmed by blood glucose levels ≥250mg/dL. Eight weeks after diabetes induction, animals were weighted and blood samples were collected from abdominal aorta for plasma levels of total homocystein, von Willebrand factor, final fasting glucose, total cholesterol and fractions (HDL-, LDL- and VLDL-cholesterol), triglycerides and creatinin. The results were expressed as the mean+SD. Data were analyzed using analysis of variance (ANOVA) followed by Tukey test or Brown Forsythe test followed by Dunnett test. Pearson test was used to correlate the parameters. The level of significance was set at p<0.05. Results: Disease model reproducibility was observed in 100% of tested animals. Mean plasma levels of initial fasting glucose according to animal group were: 85.1±5.2mg/dL for treated group, 88.9±8.2mg/dL for sham and 88.7±5.9mg/dL for control group. Statistical analysis (ANOVA) showed no significant difference among the three groups (p=0.24). Mean plasma levels of final fasting glucose, according to animal group were: 353.5±98.2mg/dL for treated group, 80.9±5.0mg/dL for sham and 85.0±7.1mg/dL for normal control. Statistical analysis showed that the difference between the treated group and the two other groups was statistically significant (p<0.01). Mean plasma concentration of homocystein according to animal groups was: 6.1±1.3µmol/L for treated group, 8.6±2.2µmol/L for sham and 7.9±2.3µmol/L for control group. Statistical analysis showed a significant difference in the three groups (p<0.01). Mean values for von Willebrand factor were: 0.18±0.4U/L for treated group, 0.16±0.2U/L for sham group and 0.15±0.3U/L for control group. Significant statistical difference was found among the three groups (p<0.05). Mean plasma levels of total cholesterol according to animal groups were: 87.5±5.9mg/dL for treated group, 107.0±38.6mg/dL for sham and 123.9±40.8mg/dL for control group. Significant statistical difference was found among the three groups (p<0.05). There was no statistical significant difference in the mean values of cholesterol fraction (LDL, HDL, VLDL), triglycerides and creatinin among the three groups. A negative correlation between final plasma glucose and weight gain, homocystein and total cholesterol, homocystein and VLDL-cholesterol and homocystein and triglycerides was found in the treated (diabetes) group. Conclusions: In this study, results from streptozotocin-induced diabetes rats showed: 1. Lower levels of homocystein; 2. Higher levels of von Willebrand factor; 3. Negative correlation between homocystein and total cholesterol; 4. No correlations between final fasting glucose and homocystein, final fasting glucose and von Willebrand factor and homocystein and von Willebrand factor; 5. Negative correlation between weight gain and final fasting glucose.BV UNIFESP: Teses e dissertaçõe

Therapeutical hypothermia after cardiopulmonary resuscitation: evidences and practical issues

Cardiac arrest survivors frequently suffer from ischemic brain injury associated with poor neurological outcome and death. Therapeutic hypothermia improves outcomes in comatose survivors after resuscitation from out-of-hospital cardiac arrest. Considering its formal recommendation as a therapy, post-return of spontaneous circulation after cardiac arrest, the objective of this study was to review the clinical aspects of therapeutic hypothermia. Non-systematic review of articles using the keywords cardiac arrest, cardiopulmonary resuscitation, cooling, hypothermia, post resuscitation syndrome in the Med-Line database was performed. References of these articles were also reviewed. Unconscious adult patients with spontaneous circulation after out-of-hospital ventricular fibrillation or pulseless ventricular tachycardia should be cooled. Moreover, for any other rhythm or in the intra-hospital scenario, such cooling may also be beneficial. There are different ways of promoting hypothermia. The cooling system should be adjusted as soon as possible to the target temperature. Mild therapeutic hypothermia should be administered under close control, using neuromuscular blocking drugs to avoid shivering. The rewarming process should be slow, and reach 36º C, usually in no less then 8 hours. When temperature increases to more than 35º C, sedation, analgesia, and paralysis could be discontinued. The expected complications of hypothermia may be pneumonia, sepsis, cardiac arrhythmias, and coagulopathy. In spite of potential complications which require rigorous control, only six patients need to be treated to save one life.Os sobreviventes de parada cardiorrespiratória freqüentemente apresentam lesão cerebral isquêmica associada a piores desfechos neurológicos e óbito. A hipotermia terapêutica melhora os desfechos entre os sobreviventes comatosos após manobras de reanimação. Considerando sua recomendação formal para emprego terapêutico pós-recuperação da circulação espontânea na parada cardiorrespiratória, o objetivo deste estudo foi rever os principais aspectos clínicos relativos à hipotermia terapêutica. Foi feita revisão através de pesquisa não-sistemática de artigos através das palavras-chave parada cardiorrespiratória, resfriamento, hipotermia, síndrome pós-reanimação na base de dados MedLine. Adicionalmente, referências destes artigos foram igualmente avaliadas. Pacientes adultos inconscientes com circulação espontânea após parada cardiorrespiratória extra-hospitalar devem ser resfriados quando o ritmo inicial for fibrilação ventricular ou taquicardia ventricular. Este resfriamento pode ser benéfico para os outros ritmos e para o ambiente intra-hospitalar. Existem várias formas diferentes de induzir a hipotermia. O sistema de resfriamento deve atingir a temperatura alvo o mais rápido possível. O reaquecimento para 36º C deve ser realizado em não menos do que 8 horas. Quando a temperatura aumenta para mais de 35º C, sedação, analgesia e paralisia podem ser descontinuadas. As complicações esperadas da hipotermia terapêutica podem incluir pneumonia, sepse, disritmias cardíacas e coagulopatias. A despeito de potenciais complicações que necessitam de cuidadosa monitoração, apenas seis pacientes precisam ser tratados com hipotermia induzida pós- parada cardiorrespiratória para salvar uma vida.Santa Casa de Misericórdia da Bahia Hospital Santa Izabel Clínica Médica e de CardiologiaSanta Casa de Misericórdia da Bahia Hospital Santa IzabelUniversidade Federal de São Paulo (UNIFESP)Instituto Dante Pazzanese de CardiologiaDuke University Clinical Research InstituteUNIFESPSciEL

Hypertensive emergencies

Emergencies and hypertensive crises are clinical situations which may represent more than 25% of all medical emergency care. Considering such high prevalence, physicians should be prepared to correctly identify these crises and differentiate between urgent and emergent hypertension. Approximately 3% of all visits to emergency rooms are due to significant elevation of blood pressure. Across the spectrum of blood systemic arterial pressure, hypertensive emergency is the most critical clinical situation, thus requiring special attention and care. Such patients present with high blood pressure and signs of acute specific target organ damage (such as acute myocardial infarction, unstable angina, acute pulmonary edema, eclampsia, and stroke). Key elements of diagnosis and specific treatment for the different presentations of hypertensive emergency will be reviewed in this article. The MedLine and PubMed databases were searched for pertinent abstracts, using the key words hypertensive crises and hypertensive emergencies. Additional references were obtained from review articles. Available English language clinical trials, retrospective studies and review articles were identified, reviewed and summarized in a simple and practical way. The hypertensive crisis is a clinical situation characterized by acute elevation of blood pressure followed by clinical signs and symptoms. These signs and symptoms may be mild (headache, dizziness, tinnitus) or severe (dyspnea, chest pain, coma or death). If the patient presents with mild symptoms, but without acute specific target organ damage, diagnosis is hypertensive urgency. However, if severe signs and symptoms and acute specific target organ damage are present, then the patient is experiencing a hypertensive emergency. Some patients arrive at the emergency rooms with high blood pressure, but without any other sign or symptom. In these cases, they usually are not taking their medications correctly. Therefore, this is not a hypertensive crisis, but rather non-controlled chronic hypertension. This type of distinction is important for those working in emergency rooms and intensive care unit. Correct diagnosis must be made to assure the most appropriate treatment.As urgências e as emergências hipertensivas são ocorrências clínicas que podem representar mais de 25% dos atendimentos a urgências médicas. O médico deverá estar habilitado a diferenciá-las, pois o prognóstico e o tratamento são distintos. Estima-se que 3% de todas as visitas às salas de emergência decorrem de elevações significativas da pressão arterial. Nos quadros relacionados a estes atendimentos, a emergência hipertensiva é a entidade clínica mais grave que merece cuidados intensivos. É caracterizada por pressão arterial marcadamente elevada e sinais de lesões de órgãos-alvo (encefalopatia, infarto agudo do miocárdio, angina instável, edema agudo de pulmão, eclâmpsia, acidente vascular encefálico). O objetivo deste estudo foi apresentar os principais pontos sobre o seu apropriado diagnóstico e tratamento. Foi realizada busca por artigos originais com os unitermos crise hipertensiva e emergência hipertensiva nas bases de dados Pubmed e MedLine nos últimos dez anos. As referências disponíveis destes artigos foram verificadas. Os artigos foram identificados e revisados e o presente estudo condensa os principais resultados descritos. Para esta revisão foram considerados ensaios clínicos em língua inglesa, estudos retrospectivos e artigos de revisão. A crise hipertensiva é a entidade clínica com aumento súbito da PA (> 180 x 120 mmHg), acompanhada por sintomas, que podem ser leves (cefaléia, tontura, zumbido) ou graves (dispnéia, dor precordial, coma e até morte), com ou sem lesão aguda de órgãos-alvo. Se os sintomas forem leves e sem lesão aguda de órgãos alvos, define-se a urgência hipertensiva. Se o quadro clínico apresentar risco de vida e refletir lesão aguda de órgãos-alvo têm-se, então, a emergência hipertensiva. Muitos pacientes também apresentam uma PA elevada demais, por não usarem suas medicações, tratando-se apenas de hipertensão arterial sistêmica crônica não controlada. Este conhecimento deve ser rotineiro ao emergencista e Intensivista no momento de decidir sobre a conduta.Santa Casa de Misericórdia da Bahia Hospital Santa Izabel Clínica Médica e de CardiologiaUniversidade Federal de São Paulo (UNIFESP) Clínica MédicaDuke University Duke Clinical Research InstituteUniversidade de São Paulo Faculdade de Medicina Instituto do CoraçãoInstituto Dante Pazzanese de Cardiologia Divisão de PesquisaUNIFESP, Clínica MédicaSciEL

An evaluation of the professional, social and demographic profile and quality of life of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil

OBJECTIVE: To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life.METHODS: Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil.RESULTS: Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams* (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU.CONCLUSIONS: The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies were mostly found in pediatrics and psychiatry, with specific deficiencies in the handling of essential equipment and in the skills necessary to adequately attend to prehospital emergencies. A disrespectful labor scenario was also found; the evaluation of quality of life showed a notable presence of pain on the SF-36 among physicians at SAMU and especially among doctors who had worked for a longer length of time at SAMU.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina (UNIFESP/EPM) Departamento de CirurgiaFaculdade de Medicina de São José do Rio Preto Departamento de CirurgiaDuke University School of Medicine Division of CardiologyUNIFESP, EPM, (UNIFESP/EPM) Depto. de CirurgiaSciEL

Development and validation of a questionnaire to assess the knowledge of mechanical ventilation in urgent care among students in their last-year medical course in Brazil

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach’s alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach’s alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil

Chronicle myeloid leukemia and hiperviscosity syndrome: case report

BACKGROUND AND OBJECTIVES: Hyperleukocytosis (> 100 x 10(9)/L) is an uncommon presentation of chronic leukemias and it can present clinical symptoms of hyperviscosity syndrome. Hearing loss and blindness rarely occurs in patients with leukemia; however, it can be strong association with hyper-viscosity syndrome. The purpose of this paper is to report a case of acute hearing loss as the initial manifestation of acute leukemia and hyper-viscosity syndrome and also mainly aspects of the intensive care treatment. CASE REPORT: A 41 year-old, male patient, who has been complaining about dizziness for six months with no response to symptomatic medications, was admitted to the emergency department with acute hearing loss. The physical examination was normal except for a bilateral hearing loss without an apparent cause. Laboratory exams showed total leukocyte: 645.000 with 66.4% blasts, hemoglobin: 7.0, hematocrit: 20.5, urea: 94, creatinine: 1.59, K: 5.6, Na: 138, INR: 1.38, TTPa: 0.89, troponin lower than 0.2, CK: 218, CKMB: 50, uric acid: 11.1. After a first hypothesis of leukemia with a high risk of hyper-viscosity complications, the patient was admitted to the Intensive Care Unit for monitoring and treatment. A bone marrow biopsy was performed and than started hidratation, hydroxyurea, allopurinol, dexamethasone. According to hematologists the patient had a chronic myeloid leukemia. Leukopheresis was performed one week after admission when total blood leukocytes were around 488.000. Ten days after the procedure the patient had no improvement of the hearing loss but total leukocytes were 10.100. He was discharge to the ward and 2 weeks later went home to continue ambulatory treatment. CONCLUSIONS: The frequency of sensitive manifestations in patients with leukemia include not only visual and hearing loss but also many others manifestations such as conductive vertigo, facial palsy and infections. Hyperviscosity syndrome due to hyperleukocytosis is also a possible cause of sensorial loss, but the syndrome is often dependent on leukocyte counts greater than (>100 x 10(9)/L).This case is a representative of rare cases in which acute sensorineural hearing loss occurred as the initial manifestation of hyper-viscosity syndrome due to leukemia.JUSTIFICATIVA E OBJETIVOS: A hiperleucocitose (> 100 x 10(9)/L) em leucemia mielóide crônica não é uma apresentação comum e pode determinar manifestações clínicas de hiper-viscosidade. As perdas auditiva e visual observadas em pacientes com leucemia são consideradas sintomas incomuns, mas fortemente associados à síndrome da hiper-viscosidade. O objetivo deste estudo foi relatar o caso de um paciente que apresentou perda da audição como manifestação inicial de leucemia mielóide crônica e síndrome de hiper-viscosidade e rever aspectos relacionados a seu tratamento em Medicina Intensiva. RELATO DO CASO: Paciente do sexo masculino, 41 anos, com queixa de tontura havia seis meses sem resposta ao tratamento sintomático, foi admitido no serviço de emergência com perda auditiva aguda. Ao exame físico encontrava-se normal, exceto por perda auditiva bilateralmente. Os exames laboratoriais demonstraram leucocitose importante (645.000), com 66,4% de blastos com características mielóides, 13,6% bastões, 15,3% segmentados, 1,4% linfócitos, 3,3% eosinófilos e plaquetas de 225.000. Devido à suspeição de leucemia com risco elevado para síndrome de hiper-viscosidade, o paciente foi admitido para tratamento na unidade de terapia intensiva. Realizado mielograma e biópsia de medula óssea que confirmaram o diagnóstico de leucemia mielóide crônica. Iniciadas hidratação, hidroxiuréia, alopurinol e dexametasona. A leucoaferese foi realizada uma semana após a admissão, quando a contagem leucocitária estava em torno de 488.000. Dez dias após o procedimento, o paciente não apresentou melhora da audição, apesar da leucometria de 10.000. Recebeu alta hospitalar em duas semanas para continuidade do tratamento ambulatorial. CONCLUSÕES: As freqüências das manifestações sensitivas em pacientes com leucemia incluem além das perdas auditiva e visual, vertigem, paralisia facial e infecções. A síndrome de hiper-viscosidade decorrente da hiper-leucocitose é uma causa possível para as perdas sensitivas, ocorrendo geralmente com contagem leucocitária superior a (> 100 x 10(9)/L). Este caso é representativo de raro caso de perda auditiva decorrente da hiper-viscosidade por leucemia.UNIFESP-EPMInstituto Dante Pazzanese de CardiologiaAMIB AMBUNIFESP, EPMSciEL

Polyneuropathy in the critical ill patient: a common diagnosis in intensive care medicine?

BACKGROUND AND OBJECTIVES: The diffuse axonal polyneuropathy, more commonly known as Critical Illness Polyneuropathy (CIP), has been discussed by authors by decades; however, it has only been deeply studied over the last thirty years, becoming more important as an important cause of long term dependence on mechanical ventilation by seriously ill patients in intensive care medicine. CONTENTS: A significant reason for such interest is due to the importance of the CIP as complication of the septic shock and in patients with multiple organ failure, as much as responsible for the prolonging hospitalization in the Intensive Care Unit, as for the gradual reduction of the chance of survival. It has been suggested that the polyneuropathy is related with cytokines and other mediators which would increase the permeability of the vases, resulting in endoneural edema and causing the axonal injury. It is difficult to do the initial diagnostic, which, in general, are only possibly recognized when the sepsis complications or the multiple organs failure have been satisfactorily controlled. The diagnosis is made through the eletroneuromiography exam, and although there is still no effective drug treatment other than the control of the basic illness, it is consensus among multidisciplinary team that the development of the CIP does not have to be understood as a way to reduce the intensity of treatment. CONCLUSIONS: Spit of your prevalence, it is still unknown the mainly factors which are physiopathology associated as soon as your correct therapy.JUSTIFICATIVA E OBJETIVOS: A polineuropatia axonal difusa, hoje mais conhecida como polineuropatia do paciente crítico (PPC), tem sido relatada por autores há décadas, porém, apenas nos últimos 30 anos, ocupa maior importância como causa de dependência prolongada de ventilação mecânica, em pacientes gravemente enfermos internados em Unidades de Terapia Intensiva. Esta revisão teve por objetivo apresentar os princípios tópicos que norteiam a fisiopatologia, diagnóstico e tratamento desta doença em Medicina intensiva. CONTEÚDO: A importância da PPC como complicação inicial do choque séptico e em pacientes com disfunção de múltiplos de órgãos e sistemas (DMOS) está claramente descrita como responsável pelo prolongamento da permanência na UTI e, também pela redução gradativa da probabilidade de sobrevida. Sugere-se que a polineuropatia esteja relacionada com as citocinas envolvidas na sepse, além de outros mediadores que aumentariam a permeabilidade dos vasos, resultando em edema endoneural e lesão axonal. Seu início é de difícil diagnóstico, geralmente sendo possível apenas quando as complicações da sepse ou falência de múltiplos órgãos tenham sido adequadamente controladas. O diagnóstico é feito através da eletroneuromiografia. Apesar de ainda não haver nenhum tratamento medicamentoso efetivo, além do controle da doença de base, é censo comum, entre equipes multidisciplinares que o desenvolvimento da PPC não deve ser entendido como forma de reduzir os esforços do tratamento. CONLUSÕES: A despeito de sua prevalência, ainda permanecem desconhecidos os fatores claramente associados à sua fisiopatologia, bem como adequada terapia para o manuseio desta condição.UNIFESP-EPMAMIB AMBUNIFESP, EPMSciEL

Intensive care of postoperative patients in bariatric surgery

BACKGROUND AND OBJECTIVES: Obesity is an epidemic disease reaching more than 300 million people all over the world. Its prevalence has increased during the past few years and according to some studies its mortality in the critically ill patient seems to be much higher, especially among patients who were submitted to surgery. This study has as objective to discuss some particularities of managing obese patients in the intensive care unit after bariatric surgery. CONTENTS: The rate of obese patient in the ICU ranges from 9% to 26% and the increase in the number of bariatric surgeries has raised the number of obese patients in the ICU. It is important to know the physiopathology of obesity and to treat its particularities during the postoperative care. Such as pulmonary restriction, that causes an increase in pulmonary complications, coronary artery disease and thromboembolic events. CONCLUSIONS: The number of patients that undergo to bariatric surgery has increased; therefore, the number of obese patients in the ICU has also risen. Different physiological events and complications in obese patients are challenges to clinical practice. The knowledge of obese physiopathology helps in the managing routine procedures and complications after bariatric surgery.JUSTIFICATIVA E OBJETIVOS: A obesidade é considerada uma epidemia e afeta mais de 300 milhões de pessoas no mundo. A sua prevalência vem aumentando significativamente nos últimos anos e a mortalidade do paciente obeso crítico, em alguns estudos, mostra-se maior, especialmente em pacientes cirúrgicos que necessitam de UTI. Este estudo teve como objetivo ressaltar as particularidades das condutas em Medicina Intensiva no pós-operatório do paciente obeso submetido à cirurgia bariátrica. CONTEÚDO: A taxa dos pacientes obesos na UTI é de 9% a 26% e o aumento no número de cirurgias bariá­tricas tem elevado o fluxo de obesos internados em UTI. A obesidade tem várias particularidades fisiopatológicas que devem ser conhecidas para melhor manuseio pós-operatório. Entre elas estão as restrições pulmonares, que leva ao aumento do número de complicações, o fator de risco para síndrome coronariana aguda eventos trombóticos. CONCLUSÕES: O número de pacientes submetidos à cirurgia bariátrica está aumentando, o que leva a maior número de pacientes obesos internados na UTI. As alterações fisiológicas da obesidade, juntamente com as complicações de um paciente crítico, são desafios para a prática médica. Portanto, é relevante conhecer a fisiopatologia da obesidade, o tratamento rotineiro das complicações no pós-operatório de cirurgia bariátrica.UNIFESP Clínica MédicaClínica Médica da UNIFESP UTIAMIB-AMBInstituto Dante Pazzanese de CardiologiaUNIFESP, Clínica MédicaClínica Médica da UNIFESP, UTISciEL

Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians

OBJECTIVE: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire’s self-assessment items for knowledge were transformed into scores. RESULTS: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil