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BACKGROUND: Static lung compliance, which is seriously affected during surgery, can lead to respiratory failure and extubation failure, which is little explored in the decision to extubate after cardiac surgery. OBJECTIVE: To evaluate static lung compliance in the postoperative period of cardiac surgery and relate its possible reduction to cases of extubation failure in patients submitted to the fast-track method of extubation. METHODS: Patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) at a state university hospital admitted to the ICU under sedation and residual block were included. Their static lung compliance was assessed on the mechanical ventilator using software that uses least squares fitting (LSF) for measurement. Within 48 hours of extubation, the patients were observed for the need for reintubation due to respiratory failure. The level of significance adopted for the statistical tests was 5%, i.e., p<0.05. RESULTS: 77 patients (75.49%) achieved successful extubation and 25 (24.51%) failed extubation. Patients who failed extubation had lower static lung compliance compared to those who succeeded (p<0.001). We identified the cut-off point for compliance through analysis of the Receiver Operating Characteristic Curve (ROC), with the cut-off point being compliance <41ml/cmH2O associated with a higher probability of extubation failure (p<0.001). In the multiple regression analysis, the influence of lung compliance (divided by the ROC curve cut-off point) was found to be 9.1 times greater for patients with compliance <41ml/cmH2O (p< 0.003). CONCLUSIONS: Static lung compliance <41ml/cmH2O is a factor that compromises the success of extubation in the postoperative period of cardiac surgery.

FUNDAMENTO: Pouco explorada na decisão de extubação no pós-operatório de cirurgia cardíaca, a complacência pulmonar estática seriamente afetada no procedimento cirúrgico pode levar à insuficiência respiratória e à falha na extubação. OBJETIVO: Avaliar a complacência pulmonar estática no pós-operatório de cirurgia cardíaca e relacionar sua possível redução aos casos de falha na extubação dos pacientes submetidos ao método fast-track de extubação. MÉTODOS: Foram incluídos pacientes que realizaram cirurgia cardíaca com uso de circulação extracorpórea (CEC) em um hospital universitário estadual admitidos na UTI sob sedação e bloqueio residual. Tiveram sua complacência pulmonar estática avaliada no ventilador mecânico por meio do software que utiliza o least squares fitting (LSF) para a medição. No período de 48 horas após a extubação os pacientes foram observados respeito à necessidade de reintubação por insuficiência respiratória. O nível de significância adotado para os testes estatísticos foi de 5%, ou seja, p<0,05. RESULTADOS: Obtiveram sucesso na extubação 77 pacientes (75,49%) e falharam 25 (24,51%). Os pacientes que falharam na extubação tiveram a complacência pulmonar estática mais baixa quando comparados aos que tiveram sucesso (p<0,001). Identificamos o ponto de corte para complacência por meio da análise da curva Receiver Operating Characteristic Curve (ROC) sendo o ponto de corte o valor da complacência <41ml/cmH2O associado com maior probabilidade de falha na extubação (p<0,001). Na análise de regressão múltipla, verificou-se a influência da complacência pulmonar (dividida pelo ponto de corte da curva ROC) com risco de falha 9,1 vezes maior para pacientes com complacência <41ml/cmH2O (p< 0,003). CONCLUSÕES: A complacência pulmonar estática <41ml/cmH2O é um fator que compromete o sucesso da extubação no pós-operatório de cirurgia cardíaca.

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Resumo Fundamento: Pouco explorada na decisão de extubação no pós-operatório de cirurgia cardíaca, a complacência pulmonar estática seriamente afetada no procedimento cirúrgico pode levar à insuficiência respiratória e à falha na extubação. Objetivo: Avaliar a complacência pulmonar estática no pós-operatório de cirurgia cardíaca e relacionar sua possível redução aos casos de falha na extubação dos pacientes submetidos ao método fast-track de extubação. Métodos: Foram incluídos pacientes que realizaram cirurgia cardíaca com uso de circulação extracorpórea (CEC) em um hospital universitário estadual admitidos na UTI sob sedação e bloqueio residual. Tiveram sua complacência pulmonar estática avaliada no ventilador mecânico por meio do software que utiliza o least squares fitting (LSF) para a medição. No período de 48 horas após a extubação os pacientes foram observados respeito à necessidade de reintubação por insuficiência respiratória. O nível de significância adotado para os testes estatísticos foi de 5%, ou seja, p<0,05. Resultados: Obtiveram sucesso na extubação 77 pacientes (75,49%) e falharam 25 (24,51%). Os pacientes que falharam na extubação tiveram a complacência pulmonar estática mais baixa quando comparados aos que tiveram sucesso (p<0,001). Identificamos o ponto de corte para complacência por meio da análise da curva Receiver Operating Characteristic Curve (ROC) sendo o ponto de corte o valor da complacência <41ml/cmH2O associado com maior probabilidade de falha na extubação (p<0,001). Na análise de regressão múltipla, verificou-se a influência da complacência pulmonar (dividida pelo ponto de corte da curva ROC) com risco de falha 9,1 vezes maior para pacientes com complacência <41ml/cmH2O (p< 0,003). Conclusões: A complacência pulmonar estática <41ml/cmH2O é um fator que compromete o sucesso da extubação no pós-operatório de cirurgia cardíaca.

Abstract Background: Static lung compliance, which is seriously affected during surgery, can lead to respiratory failure and extubation failure, which is little explored in the decision to extubate after cardiac surgery. Objective: To evaluate static lung compliance in the postoperative period of cardiac surgery and relate its possible reduction to cases of extubation failure in patients submitted to the fast-track method of extubation. Methods: Patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) at a state university hospital admitted to the ICU under sedation and residual block were included. Their static lung compliance was assessed on the mechanical ventilator using software that uses least squares fitting (LSF) for measurement. Within 48 hours of extubation, the patients were observed for the need for reintubation due to respiratory failure. The level of significance adopted for the statistical tests was 5%, i.e., p<0.05. Results: 77 patients (75.49%) achieved successful extubation and 25 (24.51%) failed extubation. Patients who failed extubation had lower static lung compliance compared to those who succeeded (p<0.001). We identified the cut-off point for compliance through analysis of the Receiver Operating Characteristic Curve (ROC), with the cut-off point being compliance <41ml/cmH2O associated with a higher probability of extubation failure (p<0.001). In the multiple regression analysis, the influence of lung compliance (divided by the ROC curve cut-off point) was found to be 9.1 times greater for patients with compliance <41ml/cmH2O (p< 0.003). Conclusions: Static lung compliance <41ml/cmH2O is a factor that compromises the success of extubation in the postoperative period of cardiac surgery.

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Abstract Introduction: A prolonged assisted ventilation (AV) period might induce complications. Objective: To compare functional capacities and muscle strength of patients under AV. Methods: This is a prospective cohort observational study. The patients selected were under mechanical ventilation in any given moment, and they were evaluated only at the time of discharge from the intensive care unit (ICU). The convenience sample of 103 was selected and divided into a group with up to six days of AV (G6) and another with seven days or more of AV (G7). The protocol proposed was: application of the Medical Research Council (MRC) scale, dynamometry, Barthel index, ability to ambulate at ICU discharge. A call was made to the patients six and 12 months after hospital discharge for the application of the Barthel index. Results: We verified that G6 patients obtained better muscular strength measured through right 14 (8-30) and left 18 (8-26) dynamometry and MRC scale 48 (44-56). Only seven (14%) patients from the G7 group were able to ambulate. G7 patients showed greater functional loss at hospital discharge 32 (15-60). After one year of hospital discharge, both groups had recovered their functional capacity 100 (100-100). Conclusion: When evaluating the process of AV, it is possible to conclude that the longer the ventilator is used, the greater the loss of strength and functionality. In addition, there is a significant recovery of functionality after one year of hospital discharge.

Resumo Introdução: Um período prolongado de ventilação assistida (VA) pode induzir complicações. Objetivo: Comparar as capacidades funcionais e a força muscular de pacientes sob VA. Métodos: Trata-se de um estudo observacional de coorte prospectivo. Os pacientes selecionados encontravam-se em ventilação mecânica em qualquer momento, sendo avaliados apenas no momento da alta da unidade de terapia intensiva (UTI). A amostra de conveniência de 103 foi selecionada e dividida em um grupo com até seis dias de VA (G6) e outro com sete dias ou mais de VA (G7). O protocolo proposto foi: aplicação da escala MRC, dinamometria, índice de Barthel, capacidade de deambulação na alta da UTI. Foi feito um chamado aos pacientes seis e 12 meses após a alta hospitalar para aplicação do índice de Barthel. Resultados: Verificamos que os pacientes do G6 obtiveram melhor força muscular medida através da dinamometria direita 14 (8-30) e esquerda 18 (8-26) e escala do MRC 48 (44-56). Apenas sete (14%) pacientes do grupo G7 conseguiram deambular. Os pacientes do G7 apresentaram maior perda funcional na alta hospitalar 32 (15-60). Após um ano da alta hospitalar, ambos os grupos recuperaram sua capacidade funcional 100 (100-100). Conclusão: Ao avaliar o processo de AV, é possível concluir que quanto maior o tempo de uso do ventilador, maior a perda de força e funcionalidade. Além disso, há uma recuperação significativa da funcionalidade após um ano da alta hospitalar.

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BACKGROUND: The early postoperative period is critical for surgical patients. SOFA, SAPS 3 and APACHE II are prognostic scores widely used to predict mortality in ICU patients. This study aimed to evaluate these index tests for their prognostic accuracy for intra-ICU and in-hospital mortalities as target conditions in patients admitted to ICU after urgent or elective surgeries and to test whether they aid in decision-making. The process comprised the assessment of discrimination through analysis of the areas under the receiver operating characteristic curves and calibration of the prognostic models for the target conditions. After, the clinical relevance of applying them was evaluated through the measurement of the net benefit of their use in the clinical decision. RESULTS: Index tests were found to discriminate regular for both target conditions with a poor calibration (C statistics-intra-ICU mortality AUROCs: APACHE II 0.808, SAPS 3 0.821 and SOFA 0.797/in-hospital mortality AUROCs: APACHE II 0.772, SAPS 3 0.790 and SOFA 0.742). Calibration assessment revealed a weak correlation between the observed and expected number of cases in several thresholds of risk, calculated by each model, for both tested outcomes. The net benefit analysis showed that all score's aggregate value in the clinical decision when the calculated probabilities of death ranged between 10 and 40%. CONCLUSIONS: In this study, we observed that the tested ICU prognostic scores are fair tools for intra-ICU and in-hospital mortality prediction in a cohort of postoperative surgical patients. Also, they may have some potential to be used as ancillary data to support decision-making by physicians and families regarding the level of therapeutic investment and palliative care.

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BACKGROUND: Prolonged use of mechanical ventilation (MV) leads to weakening of the respiratory muscles, especially in patients subjected to sedation, but this effect seems to be preventable or more quickly reversible using respiratory muscle training. The aims of the study were to assess variations in respiratory and hemodinamic parameters with electronic inspiratory muscle training (EIMT) in tracheostomized patients requiring MV and to compare these variations with those in a group of patients subjected to an intermittent nebulization program (INP). METHODS: This was a pilot, prospective, randomized study of tracheostomized patients requiring MV in one intensive care unit (ICU). Twenty-one patients were randomized: 11 into the INP group and 10 into the EIMT group. Two patients were excluded in experimental group because of hemodynamic instability. RESULTS: In the EIMT group, maximal inspiratory pressure (MIP) after training was significantly higher than that before (P = 0.017), there were no hemodynamic changes, and the total weaning time was shorter than in the INP group (P = 0.0192). CONCLUSION: The EIMT device is safe, promotes an increase in MIP, and leads to a shorter ventilator weaning time than that seen in patients treated using INP.

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ABSTRACT CONTEXT: Today, through major technological advances in diagnostic resources within medicine, evaluation and monitoring of clinical parameters at the patient's bedside in intensive care units (ICUs) has become possible. CASE REPORT: This case report presents results and interpretations from predictive mechanical ventilation weaning indexes obtained through monitoring using chest electrical bioimpedance tomography. These indexes included maximum inspiratory pressure, maximum expiratory pressure, shallow breathing index and spontaneous breathing test. These were correlated with variations in tidal volume variables, respiratory rate, mean arterial pressure and peripheral oxygen saturation. Regarding the air distribution behavior in the pulmonary parenchyma, the patient showed the pendelluft phenomenon. Pendelluft occurs due to the time constant (product of the airways resistance and compliance) asymmetry between adjacent lung. CONCLUSION: Bioelectrical impedance tomography can help in weaning from mechanical ventilation, as in the case presented here. Pendelluft was defined as a limitation during the weaning tests.

RESUMO CONTEXTO: Atualmente, com o grande avanço tecnológico em recursos para diagnósticos em medicina, a avaliação e a monitorização de parâmetros clínicos à beira leito de paciente em unidade de terapia intensiva (UTI) se tornou possível. RELATO DE CASO: Neste relato de caso, apresentam-se os resultados e a interpretação de índices preditivos de desmame da ventilação mecânica obtidos pela tomografia de bioimpedância elétrica torácica. Esses índices incluíram a pressão inspiratória máxima, pressão expiratória máxima, índice de respiração superficial e teste de respiração espontânea. Estes estavam correlacionados com as variações de volume corrente, frequência respiratória, pressão arterial média e saturação periférica de oxigênio. Quanto ao comportamento da distribuição de ar no parênquima pulmonar, o paciente apresentou o fenômeno pendelluft. O pendelluft ocorre dado pela constante de tempo (produto da resistência e complacência das vias aéreas) de forma assimétrica entre as unidades pulmonares adjacentes. CONCLUSÃO: A tomografia de bioimpedância pode auxiliar no desmame da ventilação mecânica, como no caso apresentado. Pendelluft foi definido como limitação durante a execução dos testes para desmame.

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CONTEXT:: Today, through major technological advances in diagnostic resources within medicine, evaluation and monitoring of clinical parameters at the patient's bedside in intensive care units (ICUs) has become possible. CASE REPORT:: This case report presents results and interpretations from predictive mechanical ventilation weaning indexes obtained through monitoring using chest electrical bioimpedance tomography. These indexes included maximum inspiratory pressure, maximum expiratory pressure, shallow breathing index and spontaneous breathing test. These were correlated with variations in tidal volume variables, respiratory rate, mean arterial pressure and peripheral oxygen saturation. Regarding the air distribution behavior in the pulmonary parenchyma, the patient showed the pendelluft phenomenon. Pendelluft occurs due to the time constant (product of the airways resistance and compliance) asymmetry between adjacent lung. CONCLUSION:: Bioelectrical impedance tomography can help in weaning from mechanical ventilation, as in the case presented here. Pendelluft was defined as a limitation during the weaning tests.

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Objetivo do estudo foi comparar o sistema fechado de aspiração (SFA) com o sistema aberto de aspiração (SAA) e, para cada sistema, comparar variáveis hemodinâmicas e respiratórias para cada um dos momentos. Incluídos pacientes adultos, em ventilação mecânica em pós-operatório eletivo. Variáveis registradas pré-coleta, 15 e 30 minutos após a adaptação do SFA, imediatamente, após a oxigenação pós-aspiração com SFA, nos minutos 6, 16, 31 e 61 após aspiração com o SFA. O mesmo processo foi repetido para o SAA. Foram incluídos quarenta pacientes. Quando comparado o momento imediato a pós-oxigenação com o momento 6 minutos após a aspiração foi encontrado aumento da frequência cardíaca (FC) (p = 0,04), diminuição (p= 0,034) com o momento 31 minutos e diminuição (p= 0,032) com o momento 61 minutos. Observou-se que a FC teve diminuição significativa, em todos os momentos analisados após a aspiração, comparando com o momento imediato pós-oxigenação, no SAA. Também foi evidenciado aumento (p=0,03) no valor de volume corrente (VT), quando comparado o momento 31 minutos do SFA com o SAA. Conclusão: Apesar de apresentar alterações significativas, em algumas variáveis, quando comparados os sistemas, as modificações se mantiveram dentro da normalidade e retornaram ao valor basal em uma hora após a aspiração. (AU)

The goal was to compare the closed suction system - CSS to the open suction system - OSS and, for each system, compare hemodynamic and respiratory parameters in different moments. The group was comprised of mechanically ventilated adult patients in pos operatory period. Variables were recorded before CSS adaptation, 15 and 30 minutes after CSS adaptation , immediately after post-oxygenation aspiration with CSS, 6, 16, 31 and 61 minutes after aspiration with CSS. The same process was repeated for the OSS. Forty patients were included. When compared the post-oxygenation increased heart rate was found (p=0,04) to the 6 minutes after CSS, decreased heart rate after 31 minutes (p=0.034) and 61 minutes (p=0,032) after CSS. It was observed that the HR was significantly reduced at all times examined after aspiration, compared to the time immediately post-oxygenation for the OSS. It was also demonstrated an increase (p = 0.03) in the amount of tidal volume (TV), when CSS was compared to the OSS 31 minutes after suction. Despite showing significant changes in some variables, it remained within the normal range and returned to baseline one hour after suction. (AU)

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A tomografia de impedância elétrica é um método não invasivo de visualização da mecânica respiratória beira-leito. Este exame permite observar, em tempo real, a ventilação regional pulmonar a cada ciclo respiratório com o objetivo de se otimizar e observar os efeitos imediatos dos ajustes de ventilação mecânica e\ou terapia respiratória. O objetivo é monitorar e avaliar a reexpansão pulmonar durante as manobras fisioterapêuticas de bloqueio torácico e hiperinsuflação pulmonar com AMBU® por meio do tomógrafo de impedância elétrica. Apresentação dos resultados e a interpretação da monitorização pela tomografia por impedância elétrica torácica em paciente vítima de trauma cranioencefálico, com diagnóstico de pneumonia em hemitórax esquerdo, internado na Unidade de Terapia Intensiva submetido à manobra de bloqueio torácico e a manobra de hiperinsuflação pulmonar. Previamente à manobra de bloqueio torácico, as porcentagens de áreas ventiladas foram: quadrante 1 50%, quadrante 3 34%, quadrante 2 3% e quadrante 4 11%. Após a manobra os resultados obtidos foram: quadrante 1 50%, quadrante 3 22%, quadrante 2 14% e quadrante 4 13%. Na hiperinsuflação pulmonar, previamente as porcentagens de áreas ventiladas foram: quadrante 1 33%, quadrante 3 25%, quadrante 2 22% e quadrante 4 19%. Após a hiperinsuflação pulmonar os resultados obtidos foram: quadrante 1 39%, quadrante 3 22%, quadrante 2 23% e quadrante 4 15%. Após as manobra de bloqueio torácico há redistribuição da ventilação pulmonar no pulmão contralateral e na hiperinsuflação pulmonar houve redistribuição da ventilação pulmonar em ápices pulmonares e redução em bases. A monitorização também mostra que essas manobras são eficazes para reexpansão pulmonar.

Electrical impedance tomography is a noninvasive method of visualizationof bedside respiratory mechanics. This exam allows to observe, in real-time regional lung ventilation to each] respiratory cycle with the aim of improving and observing the immediate effects of mechanical ventilation settings and or chest therapy.The goal is to monitor and evaluate the pulmonary re-expansion during chest therapy maneuvers of thoracic blockade and lung hyperinflation with Ambu® by electrical impedance tomography. Presentation of the results and interpretation of monitoring was carried out by thoracic electrical impedance in a patient victim of head trauma, diagnosed with pneumonia in the left hemithorax, admitted to the Intensive Care Unit and submitted to thoracic blocking maneuver and lung hyperinflation maneuver. Before thoracic blocking maneuver, the percentages of ventilated area were: quadrant 1 50% 3 34% quadrant, quadrant 2 and quadrant 3% 4 11%. After the maneuver the results obtained were: Quadrant 1 50% 3 22% quadrant, quadrant 2 and quadrant 4 14% 13%. In lung hyperinflation, previously the percentage of ventilated area were quadrant 1 33% 3 25% quadrant, quadrant 2 and quadrant 22% 4 19%. After lung hyperinflation the results obtained were: Quadrant 1 39% 3 22% quadrant, quadrant 2 and quadrant 4 23% 15%. After the thoracic blocking maneuver there is redistribution of pulmonary ventilation in the contralateral lung and lung hyperinflation there was redistribution of ventilation pulmonary apices and reduction in basis. Monitoring also shows that these maneuvers are effective for pulmonary re-expansion.

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OBJETIVOS: Comparar valores de pressão inspiratória máxima (PImáx) aferidos por um manovacuômetro digital e por um dispositivo eletrônico de treinamento muscular inspiratório e avaliar as repercussões hemodinâmicas após as medidas. MÉTODOS: A amostra foi composta por indivíduos acima de 18 anos, de ambos os sexos, internados na unidade de terapia intensiva, hemodinamicamente estáveis, sem uso de drogas vasoativas ou de sedação, intubados ou traqueostomizados, em processo de desmame da ventilação mecânica. Foram feitas três medidas de PImáx pelos dois equipamentos, com tempo de oclusão de 20 segundos e tempo entre as medidas de cinco minutos. Foram analisados frequência respiratória, pressão arterial média e frequência respiratória antes e após cada medida para cada equipamento utilizado. A análise estatística usou os programas Statistical Analysis System e R Project for Statistical Computing V. 3.1.2, aplicando os testes ANOVA e Wilcoxon. RESULTADOS: Foram incluídos no estudo 58 pacientes. A média das PImáx obtidas com o manovacuômetro digital foi -46,22 centímetros de água (cmH2O), enquanto a média obtida com o dispositivo de TMI foi -13,15 cmH2O (p<0,001). A frequência cardíaca apresentou aumento na comparação antes e após todas as medidas em ambos os dispositivos (p<0,0001). A pressão arterial média apresentou diferença estatisticamente significativa somente entre antes e após a primeira medida obtida pelo manovacuômetro digital, e entre antes e após a segunda medida obtida com o dispositivo de treinamento muscular inspiratório (p<0,001). A frequência respiratória apresentou variação significativa entre antes e após as três medidas em ambos dispositivos (p<0,0001). Os valores das variáveis hemodinâmicas após as medidas de PImáx permaneceram dentro dos limites da normalidade. CONCLUSÕES: O manovacuômetro digital registrou uma PImáx superior à registrada pelo dispositivo eletrônico de treinamento muscular inspiratório. Ambos os dispositivos alteraram os valores das variáveis hemodinâmicas, que entretanto permaneceram dentro da normalidade e sem repercussão clínica.

AIMS: To compare maximum inspiratory pressure (MIP) measured by a digital manometer and by an inspiratory muscle training (IMT) device and to evaluate hemodynamic changes after measurements. METHODS: The sample included male and female individuals older than 18 years admitted to an intensive care unit who were hemodynamically stable, not being treated with vasoactive drugs or sedated, intubated or tracheostomized, and who were in the process of being weaned from mechanical ventilation. MIP was measured by both devices on three different occasions, with an occlusion time of 20 seconds and a 5-minute interval between measurements. The following parameters were assessed: respiratory rate, mean arterial pressure, and respiratory rate before and after each measurement by each device. The statistical analysis was made in the Statistical Analysis System and the R Project for Statistical Computing V. 3.1.2 softwares, using the ANOVA and the Wilcoxon tests. RESULTS: Fifty-eight patients were included in the study. The mean value obtained for MIP was -46.22 centimeters of water (cmH2O) in the digital manometer and -13.15 cmH2O (p<0.001) in the IMT device. Heart rate showed a significant increase (p<0.0001) both before and after all measurements in both devices. Mean arterial pressure showed a statistically significant difference only before and after the first measurement by the digital manometer and before and after the second measurement by the IMT device (p<0.001). The respiratory rate oscillated significantly before and after the three measurements by both devices (p<0.0001). The hemodynamic parameters remained within reference values after MIP measurements. CONCLUSIONS: The digital manometer recorded a higher MIP than that measured by the IMT device. The hemodynamic parameter values oscillated in both devices, but they remained within the normal range and were not clinically significant.

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Objetivo: Caracterizar a natureza e frequência das infecções pulmonares em pacientes adultos pós-transplantados renais tardios. Métodos: Foi realizado um estudo de revisão bibliográfica nas seguintes bases de dados eletrônicas: PubMed, Scielo e Web of Science. Os critérios de elegibilidade do estudo foram: artigos publicados entre os anos de 2010 e 2015, nos idiomas inglês, português ou espanhol, do tipo: ensaios clínicos, randomizados ou não, estudos de caso-controle, estudos de coorte e estudos longitudinais em humanos. Foram excluídos os artigos cujos participantes da pesquisa fossem menores de 18 anos de idade, além dos artigos duplicados em mais de uma das bases de dados. As palavras-chave utilizadas e combinadas na pesquisa foram: pneumonia, infecção pulmonar, infecção, transplante renal, hospitalização. Resultados: Os agentes etiológicos mais incidentes são Pneumocystis jirovecii, Mycobacterium tuberculosis e Aspergillus fumigatus. As infecções pulmonares são devidas, em grande número, ao regime imunossupressor, tempo prolongado de hemodiálise, disfunção de enxerto e transmissão inter humana. Frequentemente, essas infecções evoluem com dispneia progressiva e insuficiência respiratória aguda, sendo necessária ventilação mecânica invasiva ou não invasiva. Conclusão: As evidências científicas apontam uma alta prevalência de infecções pulmonares nos pacientes transplantados renais.

Objective: The aim of this study was to characterize the nature and frequency of pulmonary infections in late post-kidney transplant adult recipients. Methods: A bibliographic review was conducted in the following electronic databases: PubMed, SciELO and Web of Science. The study eligibility criteria were articles published between the years 2010 and 2015, in English, Portuguese or Spanish, comprising clinical trials, randomized or not, case-control studies, cohort studies, and longitudinal studies in humans. Articles whose research subjects were aged under 18 years were excluded, as well as repeated articles, which appeared in more than one of the databases. The keywords used and combined in the research were: pneumonia, lung infection, infection, kidney transplantation, hospitalization. Results: The most common etiological agents are Pneumocystis jirovecii, Mycobacterium tuberculosis and Aspergillus fumigatus. Pulmonary infections are, in a large number, due to the immunosuppressive regimen, extensive length of time on hemodialysis, graft dysfunction and interhuman transmission. Often, such infections evolve with progressive dyspnea and acute respiratory failure, thus requiring invasive or non-invasive mechanical ventilation. Conclusion: The evidences point out a high prevalence of pulmonary infections in kidney transplant recipients.

Objetivo: El objetivo del estudio fue caracterizar la naturaleza y la frecuencia de las infecciones pulmonares de pacientes adultos pos trasplante renal tardío. Métodos: Se realizó um estudio de revisión bibliográfica en las siguientes bases de datos electrónicas: PubMed, Scielo y Web of Science. Los criterios de elegibilidad del estudio fueron: artículos publicados entre los años de 2010 y 2015 en los idiomas inglés, portugués o español, del tipo ensayos clínicos randomizados o no, estudios de casocontrol, estudios de cohorte y estudios longitudinales en humanos. Fueron excluidos los artículos cuyos los participantes de la investigación tenían menos de 18 años de edad, además de los artículos repetidos en más de una base de datos. Las palabrasclave utilizadas y asociadas en la investigación fueron: neumonía, infección pulmonar, infección, trasplante renal, hospitalización. Resultados: Los agentes etiológicos más incidentes son la Pneumocystis jirovecii, el Mycobacterium tuberculosis y el Aspergillus fumigatus. Las infecciones pulmonares son causadas, en su mayoría, por el régimen inmunosupresor, el largo tiempo de hemodiálisis, la disfunción del injerto y la trasmisión inter humanos. Esas infecciones evolucionan, con frecuencia, com disnea progresiva e insuficiencia respiratoria aguda y la necesidad de ventilación mecánica invasiva o no invasiva. Conclusión: Las evidencias científicas apuntan elevada prevalencia de infecciones pulmonares en los pacientes trasplantados renales.

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OBJECTIVE: A retrospective cohort study was preformed aiming to verify the presence of transient dysfunction of gas exchange in the postoperative period of cardiac surgery and determine if this disorder is linked to cardiorespiratory events. METHODS: We included 942 consecutive patients undergoing cardiac surgery and cardiac procedures who were referred to the Intensive Care Unit between June 2007 and November 2011. RESULTS: Fifteen patients had acute respiratory distress syndrome (2%), 199 (27.75%) had mild transient dysfunction of gas exchange, 402 (56.1%) had moderate transient dysfunction of gas exchange, and 39 (5.4%) had severe transient dysfunction of gas exchange. Hypertension and cardiogenic shock were associated with the emergence of moderate transient dysfunction of gas exchange postoperatively (P=0.02 and P=0.019, respectively) and were risk factors for this dysfunction (P=0.0023 and P=0.0017, respectively). Diabetes mellitus was also a risk factor for transient dysfunction of gas exchange (P=0.03). Pneumonia was present in 8.9% of cases and correlated with the presence of moderate transient dysfunction of gas exchange (P=0.001). Severe transient dysfunction of gas exchange was associated with patients who had renal replacement therapy (P=0.0005), hemotherapy (P=0.0001), enteral nutrition (P=0.0012), or cardiac arrhythmia (P=0.0451). CONCLUSION: Preoperative hypertension and cardiogenic shock were associated with the occurrence of postoperative transient dysfunction of gas exchange. The preoperative risk factors included hypertension, cardiogenic shock, and diabetes. Postoperatively, pneumonia, ventilator-associated pneumonia, renal replacement therapy, hemotherapy, and cardiac arrhythmia were associated with the appearance of some degree of transient dysfunction of gas exchange, which was a risk factor for reintubation, pneumonia, ventilator-associated pneumonia, and renal replacement therapy in the postoperative period of cardiac surgery and cardiac procedures.

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Objective: A retrospective cohort study was preformed aiming to verify the presence of transient dysfunction of gas exchange in the postoperative period of cardiac surgery and determine if this disorder is linked to cardiorespiratory events. Methods: We included 942 consecutive patients undergoing cardiac surgery and cardiac procedures who were referred to the Intensive Care Unit between June 2007 and November 2011. Results: Fifteen patients had acute respiratory distress syndrome (2%), 199 (27.75%) had mild transient dysfunction of gas exchange, 402 (56.1%) had moderate transient dysfunction of gas exchange, and 39 (5.4%) had severe transient dysfunction of gas exchange. Hypertension and cardiogenic shock were associated with the emergence of moderate transient dysfunction of gas exchange postoperatively (P=0.02 and P=0.019, respectively) and were risk factors for this dysfunction (P=0.0023 and P=0.0017, respectively). Diabetes mellitus was also a risk factor for transient dysfunction of gas exchange (P=0.03). Pneumonia was present in 8.9% of cases and correlated with the presence of moderate transient dysfunction of gas exchange (P=0.001). Severe transient dysfunction of gas exchange was associated with patients who had renal replacement therapy (P=0.0005), hemotherapy (P=0.0001), enteral nutrition (P=0.0012), or cardiac arrhythmia (P=0.0451). Conclusion: Preoperative hypertension and cardiogenic shock were associated with the occurrence of postoperative transient dysfunction of gas exchange. The preoperative risk factors included hypertension, cardiogenic shock, and diabetes. Postoperatively, pneumonia, ventilator-associated pneumonia, renal replacement therapy, hemotherapy, and cardiac arrhythmia were associated with the appearance of some degree of transient dysfunction of gas exchange, which was a risk factor for reintubation, pneumonia, ventilator-associated pneumonia, and renal replacement therapy in the postoperative period ...

Objetivo: Estudo de coorte retrospectivo com objetivo de verificar a presença de disfunção transitória da troca gasosa no pós-operatório de cirurgia cardíaca e determinar se esse transtorno está relacionado a eventos cardiorrespiratórios. Métodos: Foram incluídos 942 pacientes consecutivos submetidos à cirurgia cardíaca e procedimentos cardíacos, encaminhados para a Unidade de Terapia Intensiva, entre junho de 2007 e novembro de 2011. Resultados: A síndrome do desconforto respiratório agudo foi observada em 15 (2%) pacientes, 199 (27,75%) pacientes apresentaram disfunção transitória da troca gasosa leve, disfunção transitória da troca gasosa moderada foi observada em 402 (56,1%) pacientes e disfunção transitória da troca gasosa grave em 39 (5,4%). A presença de hipertensão arterial sistêmica e choque cardiogênico foi associada ao surgimento de disfunção transitória da troca gasosa moderada no período pós-operatório (P=0,02 e P=0,019, respectivamente) e foram considerados fatores de risco para essa disfunção (P=0,0023 e P=0,0017, respectivamente). A presença de diabetes mellitus também foi considerada um fator de risco para disfunção transitória da troca gasosa (P=0,03). Houve correlação entre a presença de pneumonia e a presença de disfunção transitória da troca gasosa moderada em 8,9% dos casos (P=0,001). A presença de disfunção transitória da troca gasosa grave foi associada a pacientes que necessitaram de hemodiálise (P=0,0005), hemoterapia (P=0,0001), nutrição enteral (P=0,0012), ou arritmia cardíaca (P=0,0451). Conclusão: A presença de hipertensão arterial sistêmica pré-operatória e choque cardiogênico foi associada à ocorrência de disfunção transitória da troca gasosa pós-operatória. Os fatores de risco pré-operatórios foram hipertensão arterial sistêmica, choque cardiogênico e diabetes. No pós-operatório, pneumonia, pneumonia associada à ventilação, hemodiálise, hemoterapia e arritmia cardíaca foram associadas com certo grau de ...

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OBJECTIVES: To evaluate plasmatic arginine vasopressin (AVP) levels in patients undergoing scheduled conventional abdominal aortic aneurysm (AAA) repair. METHODS: Plasmatic AVP concentrations were measured by radioimmunoassay in 22 non-consecutive adult patients undergoing infra-renal AAA repair. They were under combined general and epidural anesthesia at the following time frames: 1--pre-operative (T0); 2--2h (T1) and 6h (T2) after the surgical procedure; 3--in the morning at the first (T3), second (T4) and third (T5) post-operative days. Some clinical and laboratory variables were also recorded. RESULTS: The mean age of patients was 68 ± 10 years; 17 were males. Plasmatic AVP (mean ± SD; pg/mL) was within the normal range at T0 (1.4 ± 0.7; baseline), increasing significantly at T1 (62.6 ± 62.9; P<0.001) and at T2 (31.5 ± 49.7; P<0.001), with a progressive fall, returning to basal levels at T5 (2.1 ± 3.8; P = NS). Positive and statistically significant correlations were found between AVP and glycemia, serum lactate and white blood cells counts, but not with systemic arterial pressure or plasma osmolarity during the postoperative period. CONCLUSIONS: Considering that no correlations were found between AVP levels and hemodynamic or plasmatic osmolarity variations in AAA repair, it seems that stress response is mainly secondary to noxious stimulation mediated by the autonomic nervous system that is not completely blocked by anesthetics.

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OBJECTIVES: To evaluate plasmatic arginine vasopressin (AVP) levels in patients undergoing scheduled conventional abdominal aortic aneurysm (AAA) repair. METHODS: Plasmatic AVP concentrations were measured by radioimmunoassay in 22 non-consecutive adult patients undergoing infra-renal AAA repair. They were under combined general and epidural anesthesia at the following time frames: 1 - pre-operative (T0); 2 - 2h (T1) and 6h (T2) after the surgical procedure; 3 - in the morning at the first (T3), second (T4) and third (T5) post-operative days. Some clinical and laboratory variables were also recorded. RESULTS: The mean age of patients was 68±10 years; 17 were males. Plasmatic AVP (mean±SD; pg/mL) was within the normal range at T0 (1.4±0.7; baseline), increasing significantly at T1 (62.6±62.9; P<0.001) and at T2 (31.5±49.7; P<0.001), with a progressive fall, returning to basal levels at T5 (2.1±3.8; P=NS). Positive and statistically significant correlations were found between AVP and glycemia, serum lactate and white blood cells counts, but not with systemic arterial pressure or plasma osmolarity during the postoperative period. CONCLUSIONS: Considering that no correlations were found between AVP levels and hemodynamic or plasmatic osmolarity variations in AAA repair, it seems that stress response is mainly secondary to noxious stimulation mediated by the autonomic nervous system that is not completely blocked by anesthetics.

OBJETIVOS: Avaliar os níveis plasmáticos de vasopressina (AVP) em pacientes submetidos à correção convencional de aneurisma de aorta abdominal (AAA). MÉTODOS: A AVP plasmática foi mensurada por radioimunoensaio em 22 pacientes não-consecutivos submetidos à correção eletiva de AAA infrarrenal sob anestesia geral + epidural nos seguintes momentos: pré-operatório (T0); 2h (T1) e 6h (T2) após a cirurgia; e nas manhãs do primeiro (T3), segundo (T4) e terceiro (T5) dia pós-operatório (PO). Variáveis clínicas e laboratoriais de interesse também foram anotadas. RESULTADOS: A média de idade dos pacientes foi de 68±10 anos, sendo 17 homens. A AVP plasmática (média±DP; pg/ mL) estava dentro de limites normais no T0 (1,4±0,7; basal), aumentando no T1 (62,6±62,9; P<0,001) e no T2 (31,5±49,7; P<0,001), e retornando aos valores basais no T5 (2,1±3,8; P=NS). Correlações positivas e significativas foram encontradas entre a AVP e glicemia, lactato sérico e leucócitos sanguíneos, mas não com a pressão arterial sistêmica ou com a osmolaridade plasmática no PO. CONCLUSÕES: Na cirurgia de reparação de AAA, considerando que nenhuma correlação foi encontrada entre os níveis de AVP e variações hemodinâmicas ou da osmolaridade plasmática, este achado sugere que a resposta ao estresse é predominantemente secundária aos estímulos dolorosos mediados pela parte autônoma do sistema nervoso, não completamente bloqueados pelos anestésicos.

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BACKGROUND AND OBJECTIVES: Pulmonary complications in bariatric surgery are common and, therefore, alveolar recruitment maneuvers (ARM) have been used to prevent or reduce them in the postoperative period (POP). The aim of this study was to evaluate the impact of ARM performed intraoperatively in patients undergoing bariatric surgery by videolaparoscopy in the incidence of postoperative pulmonary complications. METHODS: Randomized clinical trial with 30 patients divided into control group (CG) and experimental group (EG), with analysis of spirometric, ventilatory, hemodynamic, and radiographic variables. ARM was performed in EG with positive end expiratory pressure of 30 cmH2O and inspiratory plateau pressure of 45 cmH2O for 2 minutes after pneumoperitoneum deflation. RESULTS: We observed a significant decrease in spirometric values (p ≤ 0.001) and higher incidence of pulmonary complications on chest radiograph (p=0.02) in CG, as well as significant improvement in dyspnoea Borg scale (p ≤ 0.001) in EG. CONCLUSIONS: We conclude that ARM is a safe and effective technique when used for prevention of pulmonary complications in patients undergoing bariatric surgery, resulting in more favorable radiological and spirometric findings in the experimental group compared to the control group in the PO.

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A mensuração da função respiratória oferece informações essenciais para caracterizar anormalidades pulmonares. A pressão hidrostática da água atua no tórax submerso de diversas formas, causando alterações no sistema respiratório. O objetivo deste estudo foi analisar comparativamente variáveis que avaliam a função respiratória - volume minuto (Vmin), volume corrente (Vc), capacidade vital (Cvital) e frequência respiratória (FR) - de voluntárias no solo e com o tórax submerso em piscina terapêutica aquecida. A função respiratória de 30 voluntárias saudáveis (20,9±2,1 anos; 1,64±0,07 m; 58,8±9,2 kg; índice de massa corporal 21,78±2,63 kg/m2) foi avaliada por meio de ventilômetro em solo e aos 1 e 20 minutos de imersão, com água ao nível dos ombros, em posição sentada. Após 20 minutos de imersão, foi registrado aumento estatisticamente significativo no Vmin (p=0,015) e Vc (p=0,027); e uma redução estatisticamente significativa (p=0,016) na Cvital 1 minuto após imersão, em relação aos valores obtidos em solo. O maior tempo de imersão alterou assim os valores obtidos em solo, com exceção da Cvital, que sofreu alteração significativa desde o primeiro minuto de imersão. Não foram encontradas diferenças significativas entre os valores obtidos após 1 e 20 minutos na água. O estudo permite concluir que a imersão do tórax em piscina aquecida provocou aumento no Vmin e Vc e diminuição na Cvital de voluntárias saudáveis.

Measuring respiratory function provides essential information to assess pulmonary changes. Effects of water hydrostatic pressure on the submerged chest cause changes in the respiratory system. The purpose here was to compare respiratory function variables - minute volume (MV), tidal volume (TV), vital capacity (Vitalc), and respiratory rate (RR) - on the ground and with chest submerged in water. Respiratory function of 30 healthy female volunteers (mean age 20.93 ± 2.11; weight 58.8±9.2 kg; body mass index 21.78±2.63 kg/m2) was assessed by spirometry on the ground, and 1 and 20 minutes after immersion in warm water at shoulder level in the sitting position. As compared to ground levels, statistically significant increases were found in MV (p=0.015) and TV (p=0.027) 20 minutes after immersion, as well as a significant decrease (p=0.016) in Vitalc one minute after immersion. Longer time immersion has thus altered values obtained on ground, except for Vitalc, which showed significant reduction on the first minute after chest immersion. Comparison between variable values obtained 1 and 20 minutes in water showed no significant difference. It may thus be said that chest submersion in warm water caused an increase in MV and VT and a decrease in Vitalc of healthy subjects.

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A insuficiência respiratória após a cirurgia cardíaca com utilização da circulação extracorpórea pode ser resultante de inúmeros fatores relacionados às condições do sistema respiratório no pré, intra e pós-operatório. A finalidade desta revisão é discutir alguns dos fatores relacionados à lesão pulmonar observada no período pós-operatório de cirurgia cardíaca e quais os recursos ventilatórios têm sido propostos para minimizar e/ou tratar a hipoxemia dos pacientes.

Respiratory failure after cardiopulmonary bypass heart surgery can result from many pre-, intra- or postoperative respiratory system-related factors. This review was aimed to discuss some factors related to acute lung injury observed during the postoperative period of cardiac surgery and the mechanical ventilation modalities which should be considered to prevent hypoxemia.

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Introdução: A pleurotomia durante a cirurgia cardíaca pode danificar a função respiratória durante o período pós-operatório, podendo interferir no tempo de internação hospitalar. Objetivo: Comparar os dias de internação hospitalar em pacientes submetidos à cirurgia de revascularização do miocárdio com e sem realização de pleurotomia. Métodos: A pesquisa foi composta por 20 pacientes submetidos à cirurgia de revascularização do miocárdio com circulação extracorpórea, sendo divididos em dois grupos: G1 ? pacientes que realizaram pleurotomia (n=10) e G2 ? pacientes que não realizaram pleurotomia (n=10). Resultados: Os resultados mostraram que os pacientes do grupo G1 quando comparados aos pacientes do grupo G2 obtiveram média de internação semelhante (7,2±0,78 versus 6,8±0,42 dias). Conclusão: Não houve diferença significativa no tempo de internação entre os grupos de pacientes com e sem pleurotomia.

Introduction: Pleurotomy on cardiac surgery may damage the respiratory function during the postoperative period, and may also interfere on the length of hospital stay. Objective: To compare the length of hospital stay of patients that were submitted to myocardial revascularization surgery with or without pleurotomy. Methods: This research was composed by 20 patients submitted to myocardial revascularization surgery with cardiopulmonary bypass, and they were divided into two groups: G1 ? patients submitted to pleurotomy (n=10) e G2 ? patients not submitted to pleurotomy (n=10). Results: The results showed that the G1 patients when compared to G2 patients obtained similar average length of hospital stay (7.2±0.78 versus 6.8±0.42 days). Conclusion: There was no statistical difference regarding the length of hospital stay between the groups.

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Respiratory failure after cardiopulmonary bypass heart surgery can result from many pre-, intra- or postoperative respiratory system-related factors. This review was aimed to discuss some factors related to acute lung injury observed during the postoperative period of cardiac surgery and the mechanical ventilation modalities which should be considered to prevent hypoxemia.