Utilização de oxigenação por membrana extracorpórea (ECMO) no choque cardiogênico refratário: relato de caso e revisão da literatura

Paciente de 29 anos, do sexo masculino, com miocardiopatia dilatada, evoluiu com insuficiência cardíaca refratária ao tratamento clínico. Para manter parâmetros hemodinâmicos foi necessário utilizar balão intra-aórtico e, posteriormente, instalação de oxigenação por membrana extracorpórea (ECMO) como ponte para transplante cardíaco. A ECMO permitiu estabilização, melhora das disfunções orgânicas de tal forma que o paciente chegasse ao transplante em condições hemodinâmicas adequadas. O paciente foi transplantado, evoluiu hemodinamicamente estável no pós-operatório. Duas semanas após ter saído da unidade de terapia intensiva (UTI), recebeu alta.A 29 years old male patient, with dilated cardiomyopathy, evolved with refractory heart failure to clinical treatment. To maintain hemodynamic parameters, the use of intra-aortic balloon and there after extracorporeal membrane oxygenation (ECMO) were necessary to bridge the patient to cardiac transplantation. ECMO allowed stabilization, improvement from the organs dysfunctions in a manner that the patient could be submitted to transplantation in adequate hemodynamic conditions. The patient was transplanted, evolved hemodynamically stable in the postoperative. The patient was dischared after two weeks that he had left the intensive care unit.

Intensive Perioperative Glucose Control Does Not Improve Outcomes of Patients Submitted to Open-Heart Surgery: A Randomized Controlled Trial

BACKGROUND: The objective of this study was to investigate the relationship between different target levels of glucose and the clinical outcomes of patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: We designed a prospective study in a university hospital where 109 consecutive patients were enrolled during a six-month period. All patients were scheduled for open-heart surgery requiring cardiopulmonary bypass. Patients were randomly allocated into two groups. One group consisted of 55 patients and had a target glucose level of 80-130 mg/dl, while the other contained 54 patients and had a target glucose level of 160-200 mg/dl. These parameters were controlled during surgery and for 36 hours after surgery in the intensive care unit. Primary outcomes were clinical outcomes, including time of mechanical ventilation, length of stay in the intensive care unit, infection, hypoglycemia, renal or neurological dysfunction, blood transfusion and length of stay in the hospital. The secondary outcome was a combined end-point (mortality at 30 days, infection or length of stay in the intensive care unit of more than 3 days). A p-value of <0.05 was considered significant. RESULTS: The anthropometric and clinical characteristics of the patients from each group were similar, except for weight and body mass index. The mean glucose level during the protocol period was 126.69 mg/dl in the treated group and 168.21 mg/dl in the control group (p<0.0016). There were no differences between groups regarding clinical outcomes, including the duration of mechanical ventilation, length of stay in the intensive care unit, blood transfusion, postoperative infection, hypoglycemic event, neurological dysfunction or 30-day mortality (p>0.05). CONCLUSIONS: In 109 patients undergoing cardiac surgery with cardiopulmonary bypass, both protocols of glycemic control in an intraoperative setting and in the intensive care unit were found to be safe, easily achieved and not to differentially affect clinical outcomes

Lactate and base deficit are predictors of mortality in critically ill patients with cancer

Cancer patients frequently require admission to intensive care unit. However, there are a few data regarding predictive factors for mortality in this group of patients. The aim of this study was to evaluate whether arterial lactate or standard base deficit on admission and after 24 hours can predict mortality for patients with cancer.Journal ArticleSCOPUS: ar.jinfo:eu-repo/semantics/publishe

Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

Objective: To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. Methods: A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from&nbsp;2013 to&nbsp;2019 were analyzed. After the implementation of the project InCor-Checklist “Five steps to safe cardiac surgery” in&nbsp;2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE&nbsp;II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. Results: Since&nbsp;2013, data from&nbsp;8139&nbsp;patients have been analyzed. The average annual mortality was&nbsp;5.98%. In&nbsp;2015, the instrument was used in only&nbsp;58% of patients; in contrast, it was used in&nbsp;100% of patients in&nbsp;2019. There was a decrease in surgical mortality from&nbsp;8.22% to&nbsp;3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r&nbsp;=&nbsp;88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r&nbsp;=&nbsp;94.1%). Conclusion: In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist “Five steps to safe cardiac surgery” was associated with decreased mortality after cardiac surgery

Guidelines on Management of Human Infection with the Novel Virus Influenza A (H1N1) – A Report from the Hospital das Clínicas of the University of São Paulo

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July, 2009. Since then, 9.249 cases were confirmed in Brazil, most of them concentrated in São Paulo. The Hospital das Clínicas of the University of São Paulo is a reference center for H1N1 cases in São Paulo. The purpose of this review is to analyze the evidence concerning diagnosis, prevention, and treatment of novel influenza A (H1N1) infection. In addition, we propose guidelines for the management of this pandemic emphasizing Hospital das Clínicas “bundles” for the control of the pandemic novel influenza A (H1N1)

Epidemiology of Human Infection with the Novel Virus Influenza A (H1H1) in the Hospital das Clínicas, São Paulo, Brazil – June–September 2009

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July 16, 2009. Since then, 46,810 cases of acute respiratory syndrome have been reported in Brazil, most of them concentrated in São Paulo. Through September 16, we have confirmed 9,249 cases of novel influenza A H1N1in Brazil, including 699 deaths. The mortality rate observed in Brazil is 0.47/100,000 inhabitants and varies according to region. In this period, São Paulo registered 3733 cases (40.3% of the total) of novel influenza A (H1N1) infection and 327 deaths, reflecting a mortality rate of 0.79/100,000 inhabitants

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period