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PURPOSE: The purpose of the study was to compare 2 alveolar recruitment maneuvers (ARMs) approaches in patients with subarachnoid hemorrhage (SAH) and acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS: Sixteen SAH patients with ARDS were randomized in 2 similar groups. One received ARM with continuous positive airway pressure (CPAP) of 35 cm H(2)O for 40 seconds (CPAP recruitment), whereas the other received pressure control ventilation with positive-end expiratory pressure of 15 cm H(2)O and pressure control above positive end-expiratory pressure of 35 cm H(2)O for 2 minutes (pressure control recruitment maneuver [PCRM]). Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were measured before and after ARM. The ratio of arterial oxygen tension to fraction of inspired oxygen was measured before and 1 hour after the ARM. RESULTS: After ARM, ICP was higher in CPAP recruitment (20.50 ± 4.75 vs 13.13 ± 3.56 mm Hg; P = .003); and CPP was lower in CPAP recruitment (62.38 ± 9.81 vs 79.60 ± 6.8 mm Hg; P = .001). One hour after the ARM, the ratio of arterial oxygen tension to fraction of inspired oxygen increased significantly only in PCRM (108.5 to 203.6; P = .0078). CONCLUSION: In SAH patients with ARDS, PCRM did not affect ICP and decreased CPP in safe levels, besides improving oxygenation.

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PURPOSE: The objective of this study is to evaluate the predictive performance of maximal inspiratory pressure (Pimax), airway occlusion pressure (P 0.1), and its ratio (P 0.1/Pimax) in the weaning outcome. MATERIALS AND METHODS: Seventy patients on mechanical ventilation for more than 24 hours, who fulfilled weaning criteria, were prospectively evaluated. Pimax less than -25 cm H(2)O, P 0.1 less than 4.2 cm H(2)O, and P 0.1/Pimax less than 0.14 were evaluated in all patients before spontaneous breathing trials. The receiver operating characteristic (ROC) curve was calculated to evaluate the predictive performance of each index. RESULTS: Pimax presented the area under the ROC curves smaller than those for P 0.1 and P 0.1/Pimax (0.52 x 0.76 and 0.52 x 0.78; P = .004 and P = .0006, respectively), being the criteria of worst performance. P 0.1/Pimax presented excellent predictive performance in weaned patients, with sensitivity of 98.08, but with the area under the ROC curves only slightly larger than those for P 0.1 (0.78 x 0.76, respectively; P = .69). CONCLUSION: In our study, P 0.1 and P 0.1/Pimax ratio were moderately accurate, whereas Pimax was less accurate in predicting the weaning outcome.

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JUSTIFICATIVA E OBJETIVOS: Os efeitos adversos da hipertensão intra-abdominal (PIA) são conhecidos há muitos anos, mas apenas recentemente deu-se importância à sua monitorização. Há evidências que cerca de um quarto dos centros de tratamento intensivo (CTI) não medem a PIA por falta de conhecimento da sua importância ou dificuldade na interpretação dos resultados. O objetivo deste estudo foi avaliar o conhecimento dos médicos sobre a síndrome de compartimento abdominal (SCA) e as características do seu manuseio. MÉTODO: Para a realização deste estudo foi enviado um questionário, contendo 12 perguntas sobre o assunto, para médicos que trabalham em CTI. RESULTADOS: O conhecimento das definições internacionais de SCA não parece estar influenciado pelo tempo de exercício da Medicina, mas sim pelo tempo de atividade dedicada à Medicina Intensiva. Embora a maioria esteja ciente da existência da SCA, menos da metade dos médicos que responderam ao questionário conhece as definições internacionais de 2004. A medida da PIA é realizada em pacientes com predisposição para SCA, por via intravesical, com injeção de 25 a 100 mL de líquido, com intervalos de 4 a 8 horas. Não parece existir valor de PIA (associado ou não a disfunções orgânicas) de consenso entre médicos desta pesquisa em relação ao tratamento clínico ou cirúrgico. CONCLUSÕES: O conhecimento sobre SCA é satisfatório quando considerados apenas os médicos que atuam majoritariamente em Medicina Intensiva. Contudo, é necessária a educação acerca da presença e gravidade da hipertensão intra-abdominal para grande parte dos médicos atuantes na Medicina Intensiva na região metropolitana do Rio de Janeiro.

BACKGROUND AND OBJECTIVES: The adverse effects of intra-abdominal hypertension are known for many years. Only recently proper attention has been given to routine intra-abdominal pressure (IAP) monitoring. There is evidence that a quarter of intensive care units (ICU) do not measure IAP, due to a lack of knowledge of its importance or difficulty in results interpretation. The aim of this study is investigate the knowledge of ICU physicians about abdominal compartimental syndrome and its management. METHODS: A questionnaire with 12 questions about this issue was mailed to ICU physicians. RESULTS: The current knowledge of the international definitions of ACS does not seem to be linked to the number of years of medical practice, but was associated with the time spent working on intensive care. Although most physicians are aware of the existence of ACS, less than half know the present international definitions. The IAP monitoring is performed in patients at risk for ACS, by means of the intravesical filling with 25 to 100 mL of liquids, in intervals varying from of 4 to 8 hours. There was no consensus on the value of IAP values (with or without organ dysfunctions) for the clinical or surgical treatments of ACS in this survey. CONCLUSIONS: The knowledge of ACS is satisfactory when we consider only physicians that devote most of their time to ICU work. However, it is necessary to improve education and knowledge of most intensive care physicians regarding the presence and severity of intra-abdominal hypertension in Rio de Janeiro.

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BACKGROUND AND OBJECTIVES: The adverse effects of intra-abdominal hypertension are known for many years. Only recently proper attention has been given to routine intra-abdominal pressure (IAP) monitoring. There is evidence that a quarter of intensive care units (ICU) do not measure IAP, due to a lack of knowledge of its importance or difficulty in results interpretation. The aim of this study is investigate the knowledge of ICU physicians about abdominal compartimental syndrome and its management. METHODS: A questionnaire with 12 questions about this issue was mailed to ICU physicians. RESULTS: The current knowledge of the international definitions of ACS does not seem to be linked to the number of years of medical practice, but was associated with the time spent working on intensive care. Although most physicians are aware of the existence of ACS, less than half know the present international definitions. The IAP monitoring is performed in patients at risk for ACS, by means of the intravesical filling with 25 to 100 mL of liquids, in intervals varying from of 4 to 8 hours. There was no consensus on the value of IAP values (with or without organ dysfunctions) for the clinical or surgical treatments of ACS in this survey. CONCLUSIONS: The knowledge of ACS is satisfactory when we consider only physicians that devote most of their time to ICU work. However, it is necessary to improve education and knowledge of most intensive care physicians regarding the presence and severity of intra-abdominal hypertension in Rio de Janeiro.

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Os efeitos da fisioterapia sobre a pressão intracraniana (PIC) não são totalmente esclarecidos. O objetivo deste estudo é avaliar os efeitos da fisioterapia respiratória e movimentação passiva sobre a PIC. Foram avaliados 70 pacientes com traumatismo cranioencefálico e acidente vascular cerebral com Escala de Coma de Glasgow ≤ 8. A cabeceira foi mantida em 30 graus durante o estudo. A PIC foi monitorizada durante as seguintes condutas: compressão torácica, vibração associada à compressão torácica, compressão torácica contínua unilateral, aspiração traqueal com circuito aberto e com circuito fechado, movimentação passiva de membros superiores e inferiores, rotação do quadril, mobilização escapular e flexão lateral do tronco inferior. A variação da PIC durante as condutas foi avaliada pelo teste de Wilcoxon. A PIC inicial foi de 14 ± 6,4 mm Hg. Quatro condutas alteraram a PIC de forma significativa: Flexão lateral do tronco inferior (19,1 ± 6,52 mmHg; p < 0,0001), compressão torácica unilateral contínua (19,09 ± 6,43 mmHg; p < 0,0001), aspiração traqueal com circuito aberto (19,06 ± 6,46 mmHg; p < 0,0001) e com circuito fechado (18,2 ± 7,61 mmHg; p < 0,0001). Compressão torácica unilateral contínua e flexão lateral do tronco inferior devem ser evitadas em pacientes com hipertensão intracraniana. A aspiração traqueal é inevitável, mas deve ser cautelosa.

The effects of physical therapy on intracranial pressure (ICP) are not totally clear. The aim of this study was to evaluate the effects of respiratory physical therapy and passive mobilization on ICP. Seventy patients with traumatic brain injury (TBI) and stroke with Glasgow Coma Scale (GCS) ≤ 8 were evaluated. Thirty degree head-up position was used during the study. ICP was monitored during the following procedures: chest compression, vibration associated to chest compression, unilateral continuous chest compression, tracheal suction with open circuit and closed circuit, passive mobilization of arms and legs, hip rotation, scapular mobilization and lateral flexion of the lower trunk. Wilcoxon test was used to evaluate changes on ICP during the procedures. Initial ICP was 14 ± 6.4 mmHg. Four procedures changed ICP expressively: lateral flexion of the lower trunk (19.1 ± 6.52 mmHg; p < 0.0001), unilateral continuous chest compression (19.09 ± 6.43 mmHg; p < 0.0001), tracheal suction with open circuit (19.06 ± 6.46 mmHg; p < 0.0001) and with closed circuit (18.2 ± 7.61 mmHg; p < 0.0001). Unilateral continuous chest compression and lateral flexion of the lower trunk should be avoided in patients with intracranial hypertension. Tracheal suction is unavoidable, but should be done carefully.

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