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BACKGROUND: The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV). AIM: To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure. MATERIAL AND METHODS: We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV. RESULTS: Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies. CONCLUSIONS: In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.
ANTECEDENTES: La utilidad de la traqueostomía en pacientes COVID-19 sometidos a ventilación mecánica invasiva (VMI) prolongada ha sido cuestionada. OBJETIVO: Comparar la mortalidad a 90 días en estos pacientes, con y sin traqueostomía. MATERIAL Y MÉTODOS: Estudiamos una cohorte histórica de 92 pacientes COVID-19 con VMI prolongada (>10 días). El desenlace prima-rio fue mortalidad a 90 días. Se consideraron desenlaces secundarios los días en VMI, estadía hospitalaria/UCI, frecuencia de infecciones nosocomiales, y eventos trombóticos. Mediante regresión logística se ajustó el efecto de la traqueostomía en la mortalidad, por SOFA y días de VMI. RESULTADOS: Cuarenta y seis pacientes de 54 a 66 años (72% hombres) fueron traqueostomizados. Ellos tenían una mediana de dos comorbilidades, y recibieron el procedimiento luego de una mediana de 20,5 días en VMI (rango intercuartílico: 17-26). En el análisis crudo, la mortalidad a 90 días fue menor en los pacientes con traqueostomía que en el grupo control (6,5% vs. 32,6%; p < 0,001). No obstante, luego de controlar por factores de confusión, no se encontraron diferencias en mortalidad (riesgo relativo 0,303; p = 0,233). Las infecciones asociadas a la atención de salud y la estadía en hospital/UCI fueron mayores en los pacientes traqueostomizados que en los controles. Los eventos trombóticos ocurrieron en el 42,4% de los pacientes, sin diferencias entre grupos. No hubo casos de COVID-19 en el personal de salud que realizó las traqueostomías. CONCLUSIONES: En pacientes con COVID-19 sometidos a VMI prolongada, la realización de una traqueostomía no se asocia a un exceso de mortalidad, y es un procedimiento seguro para el personal sanitario.
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Humanos , Masculino , Feminino , Respiração Artificial , COVID-19 , Traqueostomia/efeitos adversos , Estudos Retrospectivos , Mortalidade Hospitalar , Unidades de Terapia IntensivaRESUMO
BACKGROUND: The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV). AIM: To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure. MATERIAL AND METHODS: We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV. RESULTS: Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies. CONCLUSIONS: In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.
Assuntos
COVID-19 , Respiração Artificial , Masculino , Humanos , Feminino , Traqueostomia/efeitos adversos , Unidades de Terapia Intensiva , Mortalidade Hospitalar , Estudos RetrospectivosRESUMO
BACKGROUND: Persistent hyperlactatemia during septic shock is multifactorial. Hypoperfusion-related anaerobic production and adrenergic-driven aerobic generation together with impaired lactate clearance have been implicated. An excessive adrenergic response could contribute to persistent hyperlactatemia and adrenergic modulation might be beneficial. We assessed the effects of dexmedetomidine and esmolol on hemodynamics, lactate generation, and exogenous lactate clearance during endotoxin-induced septic shock. METHODS: Eighteen anesthetized and mechanically ventilated sheep were subjected to a multimodal hemodynamic/perfusion assessment including hepatic and portal vein catheterizations, total hepatic blood flow, and muscle microdialysis. After monitoring, all received a bolus and continuous infusion of endotoxin. After 1 h they were volume resuscitated, and then randomized to endotoxin-control, endotoxin-dexmedetomidine (sequential doses of 0.5 and 1.0 µg/k/h) or endotoxin-esmolol (titrated to decrease basal heart rate by 20 %) groups. Samples were taken at four time points, and exogenous lactate clearance using an intravenous administration of sodium L-lactate (1 mmol/kg) was performed at the end of the experiments. RESULTS: Dexmedetomidine and esmolol were hemodynamically well tolerated. The dexmedetomidine group exhibited lower epinephrine levels, but no difference in muscle lactate. Despite progressive hypotension in all groups, both dexmedetomidine and esmolol were associated with lower arterial and portal vein lactate levels. Exogenous lactate clearance was significantly higher in the dexmedetomidine and esmolol groups. CONCLUSIONS: Dexmedetomidine and esmolol were associated with lower arterial and portal lactate levels, and less impairment of exogenous lactate clearance in a model of septic shock. The use of dexmedetomidine and esmolol appears to be associated with beneficial effects on gut lactate generation and lactate clearance and exhibits no negative impact on systemic hemodynamics.
Assuntos
Dexmedetomidina/farmacocinética , Hemodinâmica/efeitos dos fármacos , Ácido Láctico/metabolismo , Propanolaminas/farmacocinética , Choque Séptico/tratamento farmacológico , Animais , Chile , Dexmedetomidina/efeitos adversos , Dexmedetomidina/uso terapêutico , Frequência Cardíaca/efeitos dos fármacos , Hemodinâmica/fisiologia , Hiperlactatemia/etiologia , Hiperlactatemia/fisiopatologia , Ácido Láctico/sangue , Modelos Animais , Propanolaminas/efeitos adversos , Propanolaminas/uso terapêutico , Ovinos/metabolismoRESUMO
OBJECTIVE: To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation. METHODS: Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates. RESULTS: The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma. CONCLUSION: Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using a standardized procedure.
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Broncoscopia/métodos , Tecnologia de Fibra Óptica/métodos , Respiração Artificial/métodos , Traqueostomia/métodos , Idoso , Idoso de 80 Anos ou mais , Estado Terminal , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Traqueostomia/efeitos adversosRESUMO
RESUMEN Objetivo: Evaluar eficacia y seguridad de la traqueostomía percutánea, mediante dilatación única con asistencia fibrobroncoscópica, en pacientes críticos sometidos a ventilación mecánica. Métodos: Entre los años 2004 y 2014, se incluyeron prospectivamente 512 enfermos consecutivos con indicación de traqueostomía según los criterios clínicos de nuestro centro. Un tercio de los pacientes fueron de alto riesgo. Se registraron variables demográficas, puntaje APACHE II, y días de ventilación mecánica previo a traqueostomía percutánea. La eficacia del procedimiento fue evaluada mediante tasa de éxito en su ejecución y necesidad de conversión a técnica abierta. La seguridad fue evaluada por tasa de complicaciones operatorias y postoperatorias. Resultados: La edad media del grupo fue 64 ± 18 años (203 mujeres y 309 varones). El puntaje APACHE II fue 21 ± 3. Los pacientes permanecieron en promedio 11 ± 3 días en ventilación mecánica antes de la realización de la traqueostomía percutánea. Todos los procedimientos se completaron exitosamente, sin necesidad de convertir a técnica abierta. Dieciocho pacientes (3,5%) presentaron complicaciones operatorias. Cinco pacientes experimentaron desaturación transitoria, cuatro presentaron hipotensión relacionada a la sedación, y nueve presentaron sangrado menor, pero ninguno requirió transfusión. No se registraron complicaciones graves, ni muertes asociadas al procedimiento. Once pacientes (2,1%) presentaron complicaciones postoperatorias. Siete presentaron sangrado menor y transitorio del estoma de la traqueostomía percutánea, 2 sufrieron desplazamiento de la cánula de traqueostomía y 2 desarrollaron infección superficial del estoma. Conclusión: La traqueostomía percutánea mediante la técnica de dilatación única con asistencia fibrobroncoscópica, parece ser efectiva y segura en enfermos críticos sometidos a ventilación mecánica, cuando es realizada por intensivistas experimentados mediante un abordaje ...
ABSTRACT Objective: To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation. Methods: Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates. Results: The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma. Conclusion: Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using ...
Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Respiração Artificial/métodos , Broncoscopia/métodos , Traqueostomia/métodos , Tecnologia de Fibra Óptica/métodos , Complicações Pós-Operatórias/epidemiologia , Traqueostomia/efeitos adversos , Estudos Prospectivos , Estado Terminal , Hospitais Universitários , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: Although the prognostic value of persistent hyperlactatemia in septic shock is unequivocal, its physiological determinants are controversial. Particularly, the role of impaired hepatic clearance has been underestimated and is only considered relevant in patients with liver ischemia or cirrhosis. Our objectives were to establish whether endotoxemia impairs whole body net lactate clearance, and to explore a potential role for total liver hypoperfusion during the early phase of septic shock. METHODS: After anesthesia, 12 sheep were subjected to hemodynamic/perfusion monitoring including hepatic and portal catheterization, and a hepatic ultrasound flow probe. After stabilization (point A), sheep were alternatively assigned to lipopolysaccharide (LPS) (5 mcg/kg bolus followed by 4 mcg/kg/h) or sham for a three-hour study period. After 60 minutes of shock, animals were fluid resuscitated to normalize mean arterial pressure. Repeated series of measurements were performed immediately after fluid resuscitation (point B), and one (point C) and two hours later (point D). Monitoring included systemic and regional hemodynamics, blood gases and lactate measurements, and ex-vivo hepatic mitochondrial respiration at point D. Parallel exogenous lactate and sorbitol clearances were performed at points B and D. Both groups included an intravenous bolus followed by serial blood sampling to draw a curve using the least squares method. RESULTS: Significant hyperlactatemia was already present in LPS as compared to sham animals at point B (4.7 (3.1 to 6.7) versus 1.8 (1.5 to 3.7) mmol/L), increasing to 10.2 (7.8 to 12.3) mmol/L at point D. A significant increase in portal and hepatic lactate levels in LPS animals was also observed. No within-group difference in hepatic DO2, VO2 or O2 extraction, total hepatic blood flow (point D: 915 (773 to 1,046) versus 655 (593 to 1,175) ml/min), mitochondrial respiration, liver enzymes or sorbitol clearance was found. However, there was a highly significant decrease in lactate clearance in LPS animals (point B: 46 (30 to 180) versus 1,212 (743 to 2,116) ml/min, P < 0.01; point D: 113 (65 to 322) versus 944 (363 to 1,235) ml/min, P < 0.01). CONCLUSIONS: Endotoxemia induces an early and severe impairment in lactate clearance that is not related to total liver hypoperfusion.
Assuntos
Hemodinâmica/fisiologia , Hiperlactatemia/sangue , Ácido Láctico/sangue , Hepatopatias/sangue , Taxa de Depuração Metabólica/fisiologia , Choque Séptico/sangue , Animais , Hiperlactatemia/patologia , Ácido Láctico/farmacologia , Fígado/irrigação sanguínea , Fígado/efeitos dos fármacos , Hepatopatias/patologia , Taxa de Depuração Metabólica/efeitos dos fármacos , Ovinos , Choque Séptico/patologiaRESUMO
INTRODUCTION: Physicians' adherence to pre-established criteria for the indication and/or maintenance of invasive devices is a weak point in infection control programs. Fulfillment of the recommendations for preventing infections associated with invasive devices is essential to reduce their risk. OBJECTIVE: To assess the adherence of physicians to the standardized criteria for indication of central venous catheter (CVC) and permanent urinary catheter (PUC) and to the application of supervision guidelines. METHODS: During a period of 7 months, residents of the Critical Patient Unit monitored the adherence to criteria for indication of CVC and PUC recorded in patients' medical records. This information was compared with current regulations to assess compliance. RESULTS: Between April and September 2009, 2078 supervision guidelines were applied. Invasive devices were identified in 47.7%. 10.4% of CVCs and 19.2% of PUCs did not meet criteria for installation and / or maintenance at the time of monitoring. CONCLUSIONS: Adherence of our medical staff to criteria for installation and /or maintenance of CVC and CUP should be improved. Monitoring can be efficiently performed by residents and could reduce infections associated with invasive procedures.
Assuntos
Cateterismo Venoso Central/normas , Infecção Hospitalar/prevenção & controle , Fidelidade a Diretrizes/estatística & dados numéricos , Padrões de Prática Médica/normas , Cateterismo Urinário/normas , Infecção Hospitalar/etiologia , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva , Padrões de Prática Médica/estatística & dados numéricos , Estudos ProspectivosRESUMO
Introduction: Physicians' adherence to pre-established criteria for the indication and/or maintenance of invasive devices is a weak point in infection control programs. Fulfillment of the recommendations for preventing infections associated with invasive devices is essential to reduce their risk. Objective: To assess the adherence of physicians to the standardized criteria for indication of central venous catheter (CVC) and permanent urinary catheter (PUC) and to the application of supervision guidelines. Methods: During a period of 7 months, residents of the Critical Patient Unit monitored the adherence to criteria for indication of CVC and PUC recorded in patients' medical records. This information was compared with current regulations to assess compliance. Results: Between April and September 2009, 2078 supervision guidelines were applied. Invasive devices were identified in 47.7%. 10.4% of CVCs and 19.2% of PUCs did not meet criteria for installation and / or maintenance at the time of monitoring. Conclusions: Adherence of our medical staff to criteria for installation and /or maintenance of CVC and CUP should be improved. Monitoring can be efficiently performed by residents and could reduce infections associated with invasive procedures.
Introducción: La adherencia médica a los criterios de indicación y/o mantención de procedimientos invasores es un punto débil en los programas de control de infecciones. Cumplir las recomendaciones relacionadas a prevención de infecciones asociadas a procedimientos invasores es fundamental para reducir el riesgo de infección. Objetivos: Evaluar la adherencia de médicos residentes a criterios estandarizados de indicaciones médicas de catéter venoso central (CVC) y catéter urinario permanente (CUP) y a aplicar pautas de supervisión para evaluar su cumplimiento. Método: Durante un período de siete meses, residentes de la Unidad de Paciente Crítico (UPC), monitorizaron la adherencia a los criterios de indicación de CVC y CUP registrados en las fichas clínicas de los pacientes. La información registrada se cotejó con la normativa vigente. Resultados: Entre abril y octubre de 2009 se aplicaron 2.078 pautas de supervisión, de las cuales 47,7% identificaron invasión al momento de aplicarlas. Un 10,4 y 19,2% de los CVC y CUP, respectivamente, no cumplían con criterios de instalación y/o mantención al momento de la supervisión. Conclusiones: La adherencia de nuestros médicos de UPC a los criterios de instalación y/o mantención de CVC y CUP debe mejorarse. La supervisión puede ser realizada eficientemente por los mismos residentes y podría reducir las infecciones asociadas a procedimientos invasores.
Assuntos
Humanos , Cateterismo Venoso Central/normas , Infecção Hospitalar/prevenção & controle , Fidelidade a Diretrizes/estatística & dados numéricos , Padrões de Prática Médica/normas , Cateterismo Urinário/normas , Infecção Hospitalar/etiologia , Hospitais Universitários , Unidades de Terapia Intensiva , Estudos Prospectivos , Padrões de Prática Médica/estatística & dados numéricosRESUMO
BACKGROUND: The decision of when to stop septic shock resuscitation is a critical but yet a relatively unexplored aspect of care. This is especially relevant since the risks of over-resuscitation with fluid overload or inotropes have been highlighted in recent years. A recent guideline has proposed normalization of central venous oxygen saturation and/or lactate as therapeutic end-points, assuming that these variables are equivalent or interchangeable. However, since the physiological determinants of both are totally different, it is legitimate to challenge the rationale of this proposal. We designed this study to gain more insights into the most appropriate resuscitation goal from a dynamic point of view. Our objective was to compare the normalization rates of these and other potential perfusion-related targets in a cohort of septic shock survivors. METHODS: We designed a prospective, observational clinical study. One hundred and four septic shock patients with hyperlactatemia were included and followed until hospital discharge. The 84 hospital-survivors were kept for final analysis. A multimodal perfusion assessment was performed at baseline, 2, 6, and 24 h of ICU treatment. RESULTS: Some variables such as central venous oxygen saturation, central venous-arterial pCO2 gradient, and capillary refill time were already normal in more than 70% of survivors at 6 h. Lactate presented a much slower normalization rate decreasing significantly at 6 h compared to that of baseline (4.0 [3.0 to 4.9] vs. 2.7 [2.2 to 3.9] mmol/L; p < 0.01) but with only 52% of patients achieving normality at 24 h. Sublingual microcirculatory variables exhibited the slowest recovery rate with persistent derangements still present in almost 80% of patients at 24 h. CONCLUSIONS: Perfusion-related variables exhibit very different normalization rates in septic shock survivors, most of them exhibiting a biphasic response with an initial rapid improvement, followed by a much slower trend thereafter. This fact should be taken into account to determine the most appropriate criteria to stop resuscitation opportunely and avoid the risk of over-resuscitation.
RESUMO
PURPOSE: The role of dobutamine during septic shock resuscitation is still controversial since most clinical studies have been uncontrolled and no physiological study has unequivocally demonstrated a beneficial effect on tissue perfusion. Our objective was to determine the potential benefits of dobutamine on hemodynamic, metabolic, peripheral, hepatosplanchnic and microcirculatory perfusion parameters during early septic shock resuscitation. METHODS: We designed a randomized, controlled, double-blind, crossover study comparing the effects of 2.5-h infusion of dobutamine (5 mcg/kg/min fixed-dose) or placebo in 20 septic shock patients with cardiac index ≥2.5 l/min/m(2) and hyperlactatemia. Primary outcome was sublingual perfused microvascular density. RESULTS: Despite an increasing cardiac index, heart rate and left ventricular ejection fraction, dobutamine had no effect on sublingual perfused vessel density [9.0 (7.9-10.1) vs. 9.1 n/mm (7.9-9.9); p = 0.24] or microvascular flow index [2.1 (1.8-2.5) vs. 2.1 (1.9-2.5); p = 0.73] compared to placebo. No differences between dobutamine and placebo were found for the lactate levels, mixed venous-arterial pCO2 gradient, thenar muscle oxygen saturation, capillary refill time or gastric-to-arterial pCO2 gradient. The indocyanine green plasma disappearance rate [14.4 (9.5-25.6) vs. 18.8 %/min (11.7-24.6); p = 0.03] and the recovery slope of thenar muscle oxygen saturation after a vascular occlusion test [2.1 (1.1-3.1) vs. 2.5 %/s (1.2-3.4); p = 0.01] were worse with dobutamine compared to placebo. CONCLUSIONS: Dobutamine failed to improve sublingual microcirculatory, metabolic, hepatosplanchnic or peripheral perfusion parameters despite inducing a significant increase in systemic hemodynamic variables in septic shock patients without low cardiac output but with persistent hypoperfusion.
Assuntos
Dobutamina/farmacologia , Dobutamina/uso terapêutico , Hemodinâmica/efeitos dos fármacos , Microcirculação/efeitos dos fármacos , Ressuscitação , Choque Séptico/tratamento farmacológico , Idoso , Estudos Cross-Over , Método Duplo-Cego , Humanos , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Antibiotic therapy improves the outcome of severe sepsis and septic shock, however pharmacokinetic properties are altered in this scenario. Amikacin (AMK) is an option to treat community or nosocomial infections, although standard doses might be insufficient in critically ill patients. The aim of this study was to evaluate two AMK dosage regimens in comparison with standard therapy with regard to efficacy in achieving adequate plasma levels as well as safety. In total, 99 patients with severe sepsis or septic shock were randomised to different AMK dose protocols: Group 1, 25 mg/kg/day; Group 2, 30 mg/kg/day; and Group 3, historical standard dose (15 mg/kg/day). Peak plasma concentrations at 1 h (C(max)) were determined. Pharmacokinetics was determined and renal function was monitored to evaluate toxicity. Groups were compared using bilateral T-test. Demographic characteristics of the three groups were comparable. AMK C(max) values were 57.4±9.8, 72.1±18.4 and 35.2±9.4 µg/mL, respectively (P<0.001 between Groups 1 and 2 versus Group 3, and P<0.01 between Group 1 versus Group 2). A C(max)>60 µg/mL was reached by 39%, 76% and 0% of patients in Groups 1, 2 and 3, respectively (P<0.001) and creatinine clearance at Day 28 was 95.6±47.4, 89.7±26.6 and 56.4±18.4 mL/min, respectively. In conclusion, a 30 mg/kg daily dose of AMK presents significantly higher C(max) compared with the other groups, with 76% of patients reaching recommended peak plasma levels with no association with higher nephrotoxicity. Standard doses are insufficient in critically ill patients to reach the recommended C(max).
Assuntos
Amicacina/administração & dosagem , Amicacina/efeitos adversos , Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Plasma/química , Sepse/tratamento farmacológico , Idoso , Amicacina/farmacocinética , Antibacterianos/farmacocinética , Creatinina/metabolismo , Feminino , Humanos , Testes de Função Renal , Masculino , Taxa de Depuração Metabólica , Pessoa de Meia-IdadeRESUMO
The authors describe two cases that developed organizing pneumonia (OP) associated with novel influenza A(H1N1) virus. These patients were admitted to intensive care unit (ICU) because of severe respiratory failure. After initial clinical improvement, both patients worsened their condition during their second week of ICU stay, presenting fever, increasing in inflammatory parameters and worsening in oxygen exchange and respiratory mechanics. Chest x-rays and computed tomographies showed an increment on lung infiltrates, given by areas of consolidation and ground glass opacification. Although broad-spectrum antibiotics were administered, patients showed no improvement. All cultures, including bronchoalveolar lavage samples, were negative. In both cases, an open lung biopsy was performed, and histopathological examination of the specimen was compatible with OP. Both patients were successfully treated with high-dose corticoids. The aim of this report is to alert about the possibility of OP associated with novel influenza virus in patients with severe respiratory failure.
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Pneumonia em Organização Criptogênica/virologia , Vírus da Influenza A Subtipo H1N1/isolamento & purificação , Influenza Humana/diagnóstico , Metilprednisolona/uso terapêutico , Síndrome do Desconforto Respiratório/virologia , Adulto , Antibacterianos/uso terapêutico , Biópsia por Agulha , Terapia Combinada , Pneumonia em Organização Criptogênica/diagnóstico por imagem , Pneumonia em Organização Criptogênica/tratamento farmacológico , Progressão da Doença , Feminino , Seguimentos , Humanos , Imuno-Histoquímica , Influenza Humana/complicações , Infusões Intravenosas , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Pulsoterapia , Respiração Artificial , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/terapia , Medição de Risco , Estudos de Amostragem , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
Se presenta el caso clínico de una mujer de 17 años de edad, cursando un embarazo de 33 semanas, que ingresa al hospital por trabajo de parto prematuro. Se descartó infección de la unidad feto-placentaria y materna. Se manejo mediante inhibición del trabajo de parto con fenoterol e inducción de madurez pulmonar con corticoides. Evolucionó satisfactoriamente. En el puerperio inmediato, la madre presenta cuadro de insuficiencia respiratoria aguda, por lo que debe ser trasladada a Unidad de Cuidados Intensivos donde es estabilizada inicialmente con oxígeno 100 por ciento por mascarilla de recirculación, diuréticos e infusión continua de nitroglicerina. Se realizó angiografía pulmonar por tomografía axial computarizada, que evidenció la presencia de imágenes compatibles con embolia por líquido amniótico. El diagnóstico se planteó una vez excluidos sistemáticamente los diagnósticos de edema pulmonar agudo cardiogénico, tromboembolismo pulmonar, aspiración bronquial y neumonía. La paciente evolucionó satisfactoriamente, disminuyendo paulatinamente sus requerimientos de oxígeno, siendo dada de alta días más tarde, asintomática.