Enhanced Recovery After Surgery®: resultados iniciais da implementação do programa em cirurgia de cólon e fígado na Santa Casa de Porto Alegre, Brasil

The ERAS protocol aims to reduce the stress response associated with surgery.El protocolo ERAS tiene como meta reducir la respuesta al estrés asociada a cirugía.O protocolo ERAS visa reduzir a resposta ao estresse associada à cirurgi

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Uso da mistura gasosa de hélio e oxigênio (Heliox®) no tratamento da doença respiratória obstrutiva da via aérea inferior em serviço de emergência pediátrica

OBJETIVO: Determinar se a utilização de salbutamol, em uma mistura de hélio-oxigênio (80:20), modifica a evolução e o risco de internação em pacientes pediátricos. MÉTODOS: Delineado estudo de coorte controlada que incluiu pacientes de 2 meses a 12 anos de idade, com diagnósticos de crise de asma ou bronquiolite viral. Intensidades caracterizadas de moderada a grave, aferidas através de escore clínico (pulmonary index, PI) para doença obstrutiva. Foram considerados elegíveis escores > 8. Vinte pacientes constituíram o grupo Heliox® e 40 o grupo Oxigênio. Os pacientes receberam sequencialmente, em intervalos de 20 min, até completar seis nebulizações (período de 2 h): salbutamol 0,15 mg/kg/dose (máximo 5 mg). A droga utilizou como veículo gerador do aerossol a mistura de Heliox® (80:20) ou oxigênio a 100%. Os pacientes com diagnóstico de crise aguda de asma receberam, adicionalmente, prednisolona (2 mg/kg) via oral. RESULTADOS: Onze pacientes do grupo Heliox® permaneceram necessitando de tratamento na 6ª h de atendimento, enquanto que no grupo que recebia nebulização veiculada em oxigênio, esse número foi de 38 (p = 0,034). Na 12ª h, 7 pacientes do grupo Heliox® permaneciam em observação, enquanto no grupo Oxigênio foram 27 (p = 0,02). Diferenças quanto à necessidade de suplementação de oxigênio foram observadas apenas na 6ª h de tratamento (p = 0,02). CONCLUSÕES: Heliox® (80:20), para administração de salbutamol, é efetivo no tratamento da doença obstrutiva infantil que apresente resposta à terapêutica broncodilatadora. Comparado à técnica usual de nebulização, está associado à menor permanência em sala de observação após 6 h de tratamento

Uso de surfactante exógeno no tratamento da bronquiolite viral grave: relato de caso

OBJETIVO: descrever os possíveis efeitos clínicos e laboratoriais da instilação traqueal de surfactante exógeno a um lactente com bronquiolite viral aguda grave e submetido a ventilação mecânica. RELATO: menina de 2 meses de idade com diagnóstico clínico de bronquiolite viral aguda e submetida a ventilação mecânica, necessitando de altos picos de pressão inspiratória positiva (35 a 45 cmH2O) e elevada fração de oxigênio inspirado (FiO2= 0,9), sem resposta clínica favorável ou melhora na gasometria arterial. Optou-se por instilar surfactante exógeno endotraqueal (Exosurf®, Glaxo - 50 mg/kg) para permitir utilizar um regime ventilatório menos agressivo. RESULTADOS: quatro horas após a administração do surfactante, foi possível reduzir o pico inspiratório de pressão (PIP) de 35 para 30 cmH2O; a FiO2 de 0,9 para 0,6 e aumentar a pressão positiva ao final da expiração (PEEP) de 6 para 9 cmH2O. Neste período observou-se uma elevação na relação paO2/FiO2 de 120 para 266. Ao completar 24 horas, a FiO2 pôde ser reduzida até 0,4. DISCUSSÃO: neste relato pretendemos demonstrar que a inativação do surfactante pode ser um fator decisivo na evolução desfavorável de alguns casos graves de bronquiolite. A instilação traqueal de surfactante, nestes casos, além de promover uma rápida resposta clínica, permite que se adotem técnicas ventilatórias menos agressivas

Exogenous surfactante treatment for severe acute viral bronchiolitis : case report

Objetivo: descrever os possíveis efeitos clínicos e laboratoriais da instilação traqueal de surfactante exógeno a um lactente com bronquiolite viral aguda grave e submetido a ventilação mecânica. Relato: menina de 2 meses de idade com diagnóstico clínico de bronquiolite viral aguda e submetida a ventilação mecânica, necessitando de altos picos de pressão inspiratória positiva (35 a 45 cmH2O) e elevada fração de oxigênio inspirado (FiO2= 0,9), sem resposta clínica favorável ou melhora na gasometria arterial. Optouse por instilar surfactante exógeno endotraqueal (Exosurf®, Glaxo - 50 mg/kg) para permitir utilizar um regime ventilatório menos agressivo. Resultados: quatro horas após a administração do surfactante, foi possível reduzir o pico inspiratório de pressão (PIP) de 35 para 30 cmH2O; a FiO2 de 0,9 para 0,6 e aumentar a pressão positiva ao final da expiração (PEEP) de 6 para 9 cmH2O. Neste período observou-se uma elevação na relação paO2/FiO2 de 120 para 266. Ao completar 24 horas, a FiO2 pôde ser reduzida até 0,4. Discussão: neste relato pretendemos demonstrar que a inativação do surfactante pode ser um fator decisivo na evolução desfavorável de alguns casos graves de bronquiolite. A instilação traqueal de surfactante, nestes casos, além de promover uma rápida resposta clínica, permite que se adotem técnicas ventilatórias menos agressivas.Objective: to describe the possible clinical and laboratory effects of exogenous surfactant instillation into the tracheal tube of a child with severe acute bronchiolitis undergoing mechanical ventilation. Case report: a 2-month-old girl with clinical diagnosis of acute viral bronchiolitis underwent mechanical ventilation. She required high positive inspiratory peak pressure (35 to 45 cmH2O) and high inspiratory fraction of oxygen (FiO2 = 0.9), but showed no clinical response or improvement in the arterial blood gas analysis. An exogenous surfactant (Exosurf®, Glaxo - 50 mg/kg) was used to facilitate the use of a less aggressive ventilatory strategy. Results: four hours after surfactant administration, it was possible to reduce the positive peak inspiratory pressure (PIP) from 35 to 30 cmH2O, and FiO2 from 0.9 to 0.6; and to increase the positive end-expiratory pressure (PEEP) from 6 to 9 cmH2O. During this period the paO2/FiO2 ratio increased from 120 to 266. At the end of 24 hours, FiO2 could be reduced to 0.4. Discussion: surfactant inactivation may be a decisive factor in the unfavorable evolution of some severe cases of acute bronchiolitis. The tracheal instillation of exogenous surfactant, in these cases, allows us to adopt less aggressive ventilatory strategies, and promotes rapid clinical responses

Exogenous surfactante treatment for severe acute viral bronchiolitis : case report

Objetivo: descrever os possíveis efeitos clínicos e laboratoriais da instilação traqueal de surfactante exógeno a um lactente com bronquiolite viral aguda grave e submetido a ventilação mecânica. Relato: menina de 2 meses de idade com diagnóstico clínico de bronquiolite viral aguda e submetida a ventilação mecânica, necessitando de altos picos de pressão inspiratória positiva (35 a 45 cmH2O) e elevada fração de oxigênio inspirado (FiO2= 0,9), sem resposta clínica favorável ou melhora na gasometria arterial. Optouse por instilar surfactante exógeno endotraqueal (Exosurf®, Glaxo - 50 mg/kg) para permitir utilizar um regime ventilatório menos agressivo. Resultados: quatro horas após a administração do surfactante, foi possível reduzir o pico inspiratório de pressão (PIP) de 35 para 30 cmH2O; a FiO2 de 0,9 para 0,6 e aumentar a pressão positiva ao final da expiração (PEEP) de 6 para 9 cmH2O. Neste período observou-se uma elevação na relação paO2/FiO2 de 120 para 266. Ao completar 24 horas, a FiO2 pôde ser reduzida até 0,4. Discussão: neste relato pretendemos demonstrar que a inativação do surfactante pode ser um fator decisivo na evolução desfavorável de alguns casos graves de bronquiolite. A instilação traqueal de surfactante, nestes casos, além de promover uma rápida resposta clínica, permite que se adotem técnicas ventilatórias menos agressivas.Objective: to describe the possible clinical and laboratory effects of exogenous surfactant instillation into the tracheal tube of a child with severe acute bronchiolitis undergoing mechanical ventilation. Case report: a 2-month-old girl with clinical diagnosis of acute viral bronchiolitis underwent mechanical ventilation. She required high positive inspiratory peak pressure (35 to 45 cmH2O) and high inspiratory fraction of oxygen (FiO2 = 0.9), but showed no clinical response or improvement in the arterial blood gas analysis. An exogenous surfactant (Exosurf®, Glaxo - 50 mg/kg) was used to facilitate the use of a less aggressive ventilatory strategy. Results: four hours after surfactant administration, it was possible to reduce the positive peak inspiratory pressure (PIP) from 35 to 30 cmH2O, and FiO2 from 0.9 to 0.6; and to increase the positive end-expiratory pressure (PEEP) from 6 to 9 cmH2O. During this period the paO2/FiO2 ratio increased from 120 to 266. At the end of 24 hours, FiO2 could be reduced to 0.4. Discussion: surfactant inactivation may be a decisive factor in the unfavorable evolution of some severe cases of acute bronchiolitis. The tracheal instillation of exogenous surfactant, in these cases, allows us to adopt less aggressive ventilatory strategies, and promotes rapid clinical responses

Use of digital media for the education of health professionals in the treatment of childhood asthma

OBJECTIVES: Inhalation therapy is the main treatment for asthma and its adequate use has been a factor responsible for disease control; therefore, the aim of the study was to determine whether a digital media tool, which features portability on mobile phones, modifies the assimilation of the inhalation technique. METHODS: A total of 66 professionals working in the health care area with the pediatric population were selected. They were submitted to a pre-test on their knowledge of inhalation therapy. The professionals were randomized into two groups (A and B). Group A received a media application on their mobile phones showing the steps of inhalation therapy, while group B received the same information in written form only. A post-test was applied after 15 days. The results (pre- and post-) were analyzed by two pediatric pulmonologists. RESULTS: Of the 66 professionals, 87.9% were females. Of a total possible score of ten, the mean score obtained in the pre-test was 5.3 ± 3, and in the second test, 7.5 ± 2 (p < 0.000). There were no significant differences when comparing the two groups (p = 0.726). The nurses had the lowest mean scores in the initial test (2.3 ± 2); however, they were the group that learned the most with the intervention, showing similar means to those of other groups in the second test (6.1 ± 3). CONCLUSION: There was significant improvement in knowledge about inhalation therapy in all professional categories using both methods, demonstrating that education, when available to professionals, positively modifies medical practice

Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia The IAEA INCAPS-COVID Study

BackgroundThe coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.ObjectivesThis study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.MethodsThe International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.ResultsProcedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April&nbsp;2020.ConclusionsThe COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted