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

Emergency medicine in Brazil: historical perspective, current status, and future challenges

Abstract Background Emergency medicine (EM) in Brazil has achieved critical steps toward its development in the last decades including its official recognition as a specialty in 2016. In this article, we worked in collaboration with the Brazilian Association of Emergency Medicine (ABRAMEDE) to describe three main aspects of EM in Brazil: (1) brief historical perspective; (2) current status; and (3) future challenges. Main text In Brazil, the first EM residency program was created in 1996. Only 20 years later, the specialty was officially recognized by national regulatory bodies. Prior to recognition, there were only 2 residency programs. Since then, 52 new programs were initiated. Brazil has now 54 residency programs in 16 of the 27 federative units. As of December 2020, 192 physicians have been board certified as emergency physicians in Brazil. The shortage of formal EM-trained physicians is still significant and at this point it is not feasible to have all Brazilian emergency care units and EDs staffed only with formally trained emergency physicians. Three future challenges were identified including the recognition of EM specialists in the house of Medicine, the need of creating a reliable training curriculum despite highly heterogeneous emergency care practice across the country, and the importance of fostering the development of academic EM as a way to build a strong research agenda and therefore increase the knowledge about the epidemiology and organization of emergency care. Conclusion Although EM in Brazil has accomplished key steps toward its development, there are several obstacles before it becomes a solid medical specialty. Its continuous development will depend on special attention to key challenges involving recognition, reliability, and research.http://deepblue.lib.umich.edu/bitstream/2027.42/173261/1/12245_2021_Article_400.pd

O Federalismo como Experiência: Campos Sales e as Tentativas de Estabilização da República

This article suggests an alternative interpretation of the política dos estados or política dos governadores [politics of the governors] established by Campos Sales during his time as President of Brazil. By means of an analysis of the dynamics of the procedure for the verification of credentials, of the electoral laws, and of the memories shaped in the process, we seek to prove that the impact of the reform was limited to Sales’ term in office from 1898-1902, prompting us to challenge the consolidated argument on the oligarchy in the First Brazilian Republic, which claims that the policy Sales proposed and implemented was responsible for stabilizing the political conflicts that placed the executive and parliament in opposition. The article thus demonstrates the persistence of previously existing conflicts, and suggests that the changes proposed to the regime did little to stabilize such conflicts.O artigo propõe uma interpretação alternativa à política dos estados, estabelecida por Campos Sales quando esteve à frente da Presidência da República brasileira. A partir da análise da dinâmica do processo de verificação de poderes, das leis eleitorais e das memórias construídas sobre o processo, procuramos comprovar que o impacto da reforma limitou-se ao seu quatriênio (1898-1902), o que induz à revisão de uma tese bastante consolidada, acerca do estado oligárquico na Primeira República, qual seja, a de que a política por ele proposta e implantada tenha sido responsável pela estabilização dos conflitos políticos que opunham o Executivo ao Parlamento. Deste modo, defende-se a hipótese de que os conflitos antes existentes permaneceram e que as mudanças regimentais propostas tenham tido pouco impacto sobre a estabilização dos mesmos