Tissue perfusion assesment in shock

Apesar das diversas inovações tecnológicas e do melhor entendimento fisiopatológico dos estados de choque, esta condição permanece com elevada taxa de morbimortalidade. Uma das explicações mais aceitas para a taxa elevada é o desenvolvimento da síndrome de disfunção de múltiplos órgãos (SDMO), secundária à hipoperfusão tecidual persistente. Assim, é evidente a importância da avaliação da perfusão tecidual em tais quadros, bem como possíveis interferências terapêuticas a partir da avaliação. Nesta revisão, são abordadas noções básicas sobre a monitorização clínica e laboratorial da perfusão tecidual no choque, incluindo transporte de O2, consumo e taxa de extração de O2 saturação venosa mista de O2, lactato e gradiente gastroarterial de CO2. Tais dados são fundamentais para a correta interpretação e melhor intervenção terapêutica, visando adequar o desequilíbrio presente entre oferta/consumo de O2 e, desta forma, interromper a série de eventos fisiopatológicos que resulta em SDMO e, em muitas condições, em morte. Nesse contexto, algumas metas devem ser alcançadas durante a ressuscitação de pacientes com síndrome do choque, a saber: pressão arterial média > 65 mmHg; diurese ³ 1 ml/kg/hora; débito cardíaco suficiente para manter uma SvO2 >65%; lactato sérico < 2 mmol/L, destacando que, mesmo quando normalizadas as variáveis sistêmicas de oxigenação, graves distúrbios perfusionais regionais ainda podem existir, sendo necessário recorrer à monitorização regional através da avaliação do pCO2-gap.Although new technologies have emerged and the tissue perfusion assessment has improved, shock remains with a high mortality ratio. Multiple organ dysfunction syndrome (MODS) due to tissue hypoperfusion is the best reason to explain this high mortality ratio in these patients. Hence, tissue perfusion assessment has the pivotal role in the shocked patient evaluation, because some therapeutic interventions can be performed. In this review, will be highlighted the main clinic signs and laboratories findings observed in hypoperfusion syndromes, including oxygen transport, oxygen delivery, oxygen consumption, oxygen extraction ratio, oxygen mixed venous saturation, arterial lactate end gastric-arterial CO2 gradient. These concepts are very important to understand and choose the best intervention for breaking events that are responsible for MODS development and death. The goals of resuscitation are also provided including mean arterial pressure above 65 mm Hg, mixed venous oxygen saturation above 65%, and lactate levels below 2 mMol/L. However, regional hypoperfusion can persist despite of restoring global hemodynamic variables. Hence, gastric-mucosal PCO2 could be a therapy-guide.   &nbsp

Evaluation of T tube trial as a strategy of weaning from mechanical ventilation

BACKGROUND AND OBJECTIVES: Weaning from mechanical ventilation (MV) is an important strategy to reduce morbidity and mortality in critical care patients. In this setting, this study aimed at evaluation of T-tube trial (TT) in weaning from MV. METHODS: Patient admitted in the ICU were included if they present the following inclusion criteria: MV > 24 hours, no neuromuscular disorders, PaO2/FiO2 ratio >200, hemodynamic stability, reversion of the cause of respiratory failure, adequate respiratory drive. All were submitted to TT. Failure was defined by the presence of one of these symptoms: RR > 30 ipm, hypoxemia, tachycardia, arrhythmia, hypertension or hypotension. After two hours of TT, patients without failure criteria were extubated. After 48 hours of adequate spontaneous respiration the patient was considered successful weaned. Results were considered significant if p 24 horas, ausência de doença neuromuscular, relação PaO2/FiO2 > 200, estabilidade hemodinâmica, reversão da causa da intubação traqueal e drive respiratório adequado. Todos foram submetidos ao teste de tubo T. Considerou-se falha a ocorrência de FR > 30 irpm, hipoxemia, taquicardia, disritmias cardíacas, hipertensão ou hipotensão arterial. Após 2 horas de teste TT sem critérios de falha, os pacientes foram extubados. Considerou-se como sucesso na retirada da VM a manutenção por 48 horas de autonomia ventilatória. RESULTADOS: Foram incluídos 49 pacientes com idade média de 51,8 ± 21,7 anos. As incidências de SDRA e choque séptico foram 26,5% e 32,7% e o tempo médio de VM foi 11,9 ± 13 dias. A retirada da VM ocorreu em 79,2%, re-intubação em 31,6%, com tempo médio 13 ± 8,7 horas, sendo 75% devido à falência respiratória. Não houve correlação entre extubação e níveis de hemoglobina, PaO2/FiO2, idade, sexo, SDRA ou choque séptico prévios. O sucesso da retirada da VM (48 horas de autonomia) não se correlacionou com nenhuma das variáveis descritas. Os resultados foram considerados significativos se p < 0,05. CONCLUSÕES: O tubo T mostrou ser método adequado para a retirada da VM na maioria dos pacientes. Entretanto, a taxa de re-intubação foi elevada, podendo ser conseqüência do longo tempo do TT, da ventilação mecânica prévia ou da falha dos critérios de indicação de extubação traqueal.UNIFESP-EPM Unidade de Terapia Intensiva da Disciplina de Anestesiologia, Dor e Terapia IntensivaUNIFESP-EPMUNIFESP, EPM, Unidade de Terapia Intensiva da Disciplina de Anestesiologia, Dor e Terapia IntensivaUNIFESP, EPMSciEL

Mobilization practices in the ICU: A nationwide 1-day point- prevalence study in Brazil.

BackgroundMobilization of critically ill patients is safe and may improve functional outcomes. However, the prevalence of mobilization activities of ICU patients in Brazil is unknown.MethodsA one-day point prevalence prospective study with a 24-hour follow-up period was conducted in Brazil. Demographic data, ICU characteristics, prevalence of mobilization activities, level of patients' mobilization, and main reasons for not mobilizing patients were collected for all adult patients with more than 24hs of ICU stay in the 26 participating ICUs. Mobilization activity was defined as any exercise performed during ICU stay.ResultsIn total, 358 patients were included in this study. Mobilization activities were performed in 87.4% of patients. Patients received mobilization activities while under invasive mechanical ventilation (44.1%), noninvasive ventilation (11.7%), or without any ventilatory support (44.2%). Passive exercises were more frequently performed [46.5% in all patients; 82.3% in mechanically ventilated patients]. Mobilization activities included in-bed exercise regimen (72.2%). Out-of-bed mobility was reported in 39.9% of mobilized patients, and in 16.3% of patients under invasive mechanical ventilation. The presence of an institutional early mobility protocol was associated with early mobilization (OR, 3.19; 95% CI, 1.23 to 8.22; p = 0.016), and with out-of-bed exercise (OR, 5.80; 95% CI, 1.33 to 25.30; p = 0.02).ConclusionMobilization activities in critically ill patients in Brazil was highly prevalent, although there was almost no active mobilization in the mechanically ventilated patients. Moreover, the presence of an institutional early mobility protocol was associated with a threefold higher chance of ICU mobilization during that day

SPSS data bank

The de-identified data presented here has been used for the analyses reported in the manuscript "NIGHTTIME INTENSIVE CARE UNIT DISCHARGE AND OUTCOMES: A PROPENSITY MATCHED RETROSPECTIVE COHORT STUDY", including baseline characteristics of study participants and the main clinical outcomes before propensity score matching

Expression of genes belonging to the interacting TLR cascades, NADPH-oxidase and mitochondrial oxidative phosphorylation in septic patients

<div><p>Background and objectives</p><p>Sepsis is a complex disease that is characterized by activation and inhibition of different cell signaling pathways according to the disease stage. Here, we evaluated genes involved in the TLR signaling pathway, oxidative phosphorylation and oxidative metabolism, aiming to assess their interactions and resulting cell functions and pathways that are disturbed in septic patients.</p><p>Materials and methods</p><p>Blood samples were obtained from 16 patients with sepsis secondary to community acquired pneumonia at admission (D0), and after 7 days (D7, N = 10) of therapy. Samples were also collected from 8 healthy volunteers who were matched according to age and gender. Gene expression of 84 genes was performed by real-time polymerase chain reactions. Their expression was considered up- or down-regulated when the fold change was greater than 1.5 compared to the healthy volunteers. A p-value of ≤ 0.05 was considered significant.</p><p>Results</p><p>Twenty-two genes were differently expressed in D0 samples; most of them were down-regulated. When gene expression was analyzed according to the outcomes, higher number of altered genes and a higher intensity in the disturbance was observed in non-survivor than in survivor patients. The canonical pathways altered in D0 samples included interferon and iNOS signaling; the role of JAK1, JAK2 and TYK2 in interferon signaling; mitochondrial dysfunction; and superoxide radical degradation pathways. When analyzed according to outcomes, different pathways were disturbed in surviving and non-surviving patients. Mitochondrial dysfunction, oxidative phosphorylation and superoxide radical degradation pathway were among the most altered in non-surviving patients.</p><p>Conclusion</p><p>Our data show changes in the expression of genes belonging to the interacting TLR cascades, NADPH-oxidase and oxidative phosphorylation. Importantly, distinct patterns are clearly observed in surviving and non-surviving patients. Interferon signaling, marked by changes in JAK-STAT modulation, had prominent changes in both survivors and non-survivors, whereas the redox imbalance (iNOS signaling, oxidative phosphorylation and superoxide radical degradation) affecting mitochondrial functions was prominent in non-surviving patients.</p></div

Fold change ratios in the gene expression of septic patients compared to the healthy volunteers at admission and after seven days of follow-up, according to the outcomes.

<p>Fold change ratios in the gene expression of septic patients compared to the healthy volunteers at admission and after seven days of follow-up, according to the outcomes.</p

Demonstration of differential gene expression profile in septic patients in admission (D0) samples using curated pathway functional of IPA.

<p>A. all patients; B. survivors; and C. non-survivors. Gene expression changes with FC ≥ 1.5 and P value ≤ 0.05 were used to generate the interaction network. The intensity of the color represents up-regulation (red), down-regulation (green) or no significant regulation (gray).</p

Volcano plot representing the gene expression changes in admission samples (D0) of septic patients compared to healthy volunteers.

<p>A. all patients; B. survivors; and C. non-survivors. The x axis represents the Log₂ fold change and Y axis—Log₁₀ <i>P</i> value. The cut off for significance is set as the fold change ≥ 1.5 and P value ≤ 0.05. The genes are represented as dots, where the green color represents down regulation, red represents up regulation and gray indicates no significant changes.</p

Gene expression changes and network of interactions between control and septic patients after 7 days.

<p>Gene expression changes with FC≥ 1.5 and P value ≤ 0.05 were used to generate the interaction network. The intensity of the color represents up-regulation (red), down-regulation (green) or no regulation (gray).</p