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The SUR1-TRPM4-AQP4 complex is overexpressed in the initial phase of edema induced after cerebral ischemia, allowing the massive internalization of Na+ and water within the brain micro endothelial cells (BMEC) of the blood-brain barrier. The expression of the Abcc8 gene encoding SUR1 depends on transcriptional factors that are responsive to oxidative stress. Because reactive oxygen species (ROS) are generated during cerebral ischemia, we hypothesized that antioxidant compounds might be able to regulate the expression of SUR1. Therefore, the effect of resveratrol (RSV) on SUR1 expression was evaluated in the BMEC cell line HBEC-5i subjected to oxygen and glucose deprivation (OGD) for 2 h followed by different recovery times. Different concentrations of RSV were administered. ROS production was detected with etidine, and protein levels were evaluated by Western blotting and immunofluorescence. Intracellular Na+ levels and cellular swelling were detected by imaging; cellular metabolic activity and rupture of the cell membrane were detected by MTT and LDH release, respectively; and EMSA assays measured the activity of transcriptional factors. OGD/recovery increased ROS production induced the AKT kinase activity and the activation of SP1 and NFκB. SUR1 protein expression and intracellular Na+ concentration in the HBEC-5i cells increased after a few hours of OGD. These effects correlated with cellular swelling and necrotic cell death, responses that the administration of RSV prevented. Our results indicate that the ROS/AKT/SP1-NFκB pathway is involved in SUR1 expression during OGD/recovery in BMEC of the blood-brain barrier. Thus, RSV prevented cellular edema formation through modulation of SUR1 expression.
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Isquemia Encefálica , Oxigênio , Humanos , Resveratrol/farmacologia , Oxigênio/metabolismo , Células Endoteliais/metabolismo , Espécies Reativas de Oxigênio/metabolismo , Proteínas Proto-Oncogênicas c-akt/metabolismo , Glucose/metabolismo , Encéfalo/metabolismo , Isquemia Encefálica/metabolismo , Infarto Cerebral/metabolismo , EdemaRESUMO
INTRODUCTION AND OBJECTIVES: Acute liver failure, also known as fulminant hepatic failure (FHF), includes a spectrum of clinical entities characterized by acute liver injury, severe hepatocellular dysfunction and hepatic encephalopathy. The objective of this study was to assess cerebral autoregulation (CA) in 25 patients (19 female) with FHF and to follow up with seventeen of these patients before and after liver transplantation. PATIENTS AND METHODS: The mean age was 33.8 years (range 14-56, SD 13.1 years). Cerebral hemodynamics was assessed by transcranial Doppler (TCD) bilateral recordings of cerebral blood velocity (CBv) in the middle cerebral arteries (MCA). RESULTS: CA was assessed based on the static CA index (SCAI), reflecting the effects of a 20-30 mmHg increase in mean arterial blood pressure on CBv induced with norepinephrine infusion. SCAI was estimated at four time points: pretransplant and on the 1st, 2nd and 3rd posttransplant days, showing a significant difference between pre- and posttransplant SCAI (p = 0.005). SCAI peaked on the third posttransplant day (p = 0.006). Categorical analysis of SCAI showed that for most patients, CA was reestablished on the second day posttransplant (SCAI > 0.6). CONCLUSIONS: These results suggest that CA impairment pretransplant and on the 1st day posttransplant was re-established at 48-72 h after transplantation. These findings can help to improve the management of this patient group during these specific phases, thereby avoiding neurological complications, such as brain swelling and intracranial hypertension.
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Encefalopatia Hepática , Falência Hepática Aguda , Transplante de Fígado , Humanos , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Transplante de Fígado/efeitos adversos , Encefalopatia Hepática/diagnóstico por imagem , Encefalopatia Hepática/etiologia , Falência Hepática Aguda/diagnóstico , Falência Hepática Aguda/cirurgia , Falência Hepática Aguda/complicações , Homeostase/fisiologiaRESUMO
Previous studies suggest that craniofacial manual lymphatic drainage (MLD) facilitates brain fluids clearance, reducing intracranial pressure and reabsorbing chronic subdural hematoma. This study aimed to explore the effect of craniofacial MLD in combination with pharmacological treatment for improving cranial pain intensity, vital signs, and cerebral edema (Hounsfield units, HUs) in moderate traumatic brain injury (mTBI). Patient 1 received pharmacological therapy, while patient 2 received both pharmacological and craniocervical MLD treatment. Patient 2 showed decreased cranial pain intensity and systolic blood pressure (66%-11.11%, respectively) after two 30 min daily sessions of treatment for three days. HUs in the caudate nucleus of both hemispheres (left 24.64%-right 28.72%) and in the left temporal cortical gray matter increased (17.8%). An increase in HU suggests a reduction in cerebral edema and vice versa. For patient 1, there were no changes in cranial pain intensity, but a slight increase in the systolic blood pressure was observed (0%-3.27%, respectively). HUs decreased in the temporal cortical (14.98%) and caudate nucleus gray matter (9.77%) of the left and right cerebral hemispheres (11.96%-16.74%, respectively). This case study suggests that craniofacial MLD combined with pharmacological treatment could reduce cerebral edema, decrease head pain intensity, and maintain vital signs in normal physiologic values in patients with mTBI.
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ABSTRACT A large world population resides at moderate altitudes. In the Valley of Mexico (2240 m above sea level) and for patients with respiratory diseases implies more hypoxemia and clinical deterioration, unless supplementary oxygen is prescribed or patients move to sea level. A group of individuals residing at 2500 or more meters above sea level may develop acute or chronic mountain disease but those conditions may develop at moderate altitudes although less frequently and in predisposed individuals. In the valley of México, at 2200 m above sea level, re-entry pulmonary edema has been reported. The frequency of other altitude-related diseases at moderate altitude, described in skiing resorts, remains to be known in visitors to Mexico City and other cities at similar or higher altitudes. Residents of moderate altitudes inhale deeply the city's air with all pollutants and require more often supplementary oxygen.
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A large world population resides at moderate altitudes. In the Valley of Mexico (2240 m above sea level) and for patients with respiratory diseases implies more hypoxemia and clinical deterioration, unless supplementary oxygen is prescribed or patients move to sea level. A group of individuals residing at 2500 or more meters above sea level may develop acute or chronic mountain disease but those conditions may develop at moderate altitudes although less frequently and in predisposed individuals. In the valley of México, at 2200 m above sea level, re-entry pulmonary edema has been reported. The frequency of other altituderelated diseases at moderate altitude, described in skiing resorts, remains to be known in visitors to Mexico City and other cities at similar or higher altitudes. Residents of moderate altitudes inhale deeply the city's air with all pollutants and require more often supplementary oxygen.
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Doença da Altitude , Edema Pulmonar , Humanos , Altitude , Doença da Altitude/epidemiologia , Doença da Altitude/etiologia , Hipóxia/epidemiologia , Hipóxia/etiologia , Edema Pulmonar/epidemiologia , Edema Pulmonar/etiologia , OxigênioRESUMO
Resumen: Introducción: La trombosis venosa cerebral (TVC) es una enfermedad grave que afecta con mayor frecuencia a adultos jóvenes, con una incidencia de tres casos por cada 1'000,000 de habitantes en edad adulta. Aproximadamente se reporta 0.5% de los eventos vasculares cerebrales, siendo más frecuente en el género femenino, como factores de riesgo importante está el embarazo, parto, puerperio y uso de anticonceptivos orales (ACO). Caso clínico: Femenino de 34 años, con 8.2 semanas de gestación (SDG) normoevolutivo, que inicia siete días previos a su ingreso con cefalea occipital de intensidad moderada, que se intensifica progresivamente y empeoraba al estar acostada, agregándose náuseas y vómitos, sugestivos de cráneo hipertensivo, por lo que acude a hospital, donde ingresa con Glasgow de 15 puntos, se realiza resonancia magnética (RM), que muestra trombosis del seno venoso transverso izquierdo y hemorragia intraparenquimatosa temporoparietal izquierda, presenta deterioro del estado neurológico, requiere manejo avanzado de vía aérea y traslado a Unidad de Cuidados Intensivos (UCI). La tomografía de cráneo (TC) de ingreso a UCI con hematoma parenquimatoso temporoparietal izquierdo, edema cerebral, colapso de sistema ventricular lateral ipsilateral y desviación de la línea media, valorada por neurocirugía, quien descarta procedimiento quirúrgico y se inicia terapia osmolar con soluciones hipertónicas al 7.5%. La TC cinco días después muestra infarto cerebral en hemisferio izquierdo y sangrado intraparenquimatoso antiguo, el cual se encuentra en procesos de reabsorción; sin embargo, edema cerebral severo, que requiere de craniectomía parietofrontal izquierda. La TC de control con disminución del edema, logrando progresar y destetar de la ventilación mecánica, egresándose a piso de ginecología con Glasgow de 14 puntos y embarazo de 10.2 SDG normoevolutivo. Conclusiones: Esta patología es potencialmente reversible con un diagnóstico precoz y atención médica adecuada. La RM es el estudio de elección.
Abstract: Introduction: Cerebral venous thrombosis (CVT) is a serious disease that most frequently affects young adults, with an incidence of three cases per million adult inhabitants. It is the cause of 0.5% of cerebral vascular events. It is more frequent in women, is associated with childbirth, puerperium and the use of oral contraceptives. Clinical case: Female, 34 years old, with 8.2 weeks of gestation, which began seven days prior to admission with intense headache, nausea and vomiting, suggestive of hypertensive skull; went to hospital, where he was admitted with Glasgow 15 points, MRI was performed, which showed thrombosis of the left transverse venous sinus and left parietal temporo intraparenchymal hemorrhage, showed deterioration of neurological status, and required advanced airway management and transfer to Intensive Care Unit. CT (computed tomography) of the skull on admission to the Intensive Care Unit showed parenchymal left parietal temporo hematoma, cerebral edema, collapse of the ipsilateral lateral ventricular system and deviation of the midline. Neurosurgery assessed who ruled out surgical procedure and began osmolar therapy with hypertonic solutions at 7.5%. CT scan five days later showed cerebral infarction in the left hemisphere and old intraparenchymal bleeding in reabsorption process but severe cerebral edema, which required left parietal frontal craniectomy. The control CT scan with decreased edema, achieving weaning from mechanical ventilation, graduated to the floor of gynecology with Glasgow 14 points and pregnancy of 10.2 SDG. Conclusions: It is very important the correct diagnosis and not to confuse pregnancy alterations with neurological symptoms. MR is the study of choice.
Resumo: Introdução: A trombose venosa cerebral (TVC) é uma doença grave que acomete mais frequentemente adultos jovens, com incidência de 3 casos 1'000,000 habitantes na idade adulta. Aproximadamente são relatados 0.5% dos eventos vasculares cerebrais, sendo mais frequentes no sexo feminino, como fatores de risco importantes estão a gravidez, parto, puerpério e uso de anticoncepcionais orais (AO). Caso clínico: Paciente do sexo feminino, 34 anos, com 8.2 semanas de gestação (SDG) evoluindo normalmente, que iniciou 7 dias antes da internação com cefaléia occipital de intensidade moderada, que se intensificava progressivamente e piorava ao deitar, somando-se náuseas e vômitos, sugestivos de crânio hipertenso, busca atenção hospitalar, onde é internada com um Glasgow de 15 pontos, realiza-se ressonância magnética (RM), que mostra trombose do seio venoso transverso esquerdo e hemorragia intraparenquimatosa temporomandibular esquerda, apresenta deterioração do quadro neurológico e requer manejo avançado das vias aéreas e transferência para a Unidade de Terapia Intensiva (UTI). A tomografia de crânio (TC) na admissão na UTI mostrou hematoma parietal temporal esquerdo, edema cerebral, colapso do sistema ventricular lateral ipsilateral e desvio da linha média, avaliada por neurocirurgia que descartou procedimento cirúrgico e iniciou terapia osmolar com soluções hipertônicas a 7.5%. A TC 5 dias depois mostra infarto cerebral no hemisfério esquerdo e sangramento intraparenquimatoso antigo que está em reabsorção, porém edema cerebral grave, que requer craniectomia parietofrontal esquerda. A TC de controle mostrou diminuição do edema, progredindo ao desmame da ventilação mecânica, alta para o andar de ginecologia com escore de Glasgow de 14 e gravidez de 10.2 SDG evoluindo normalmente. Conclusões: Esta patologia é potencialmente reversível com diagnóstico precoce e cuidados médicos adequados. A ressonância magnética é o estudo de eleição.
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Background and purpose: The novel coronavirus, SARS-CoV-2, which was identified after the outbreak in Wuhan, China, in December 2019, has kept the whole world in tenterhooks due to its severe life-threatening nature of the infection. The World Health Organization (WHO) declared coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 a pandemic in 2020, an unprecedented challenge, having a high contagious life-threatening condition with unprecedented impacts for worldwide societies and health care systems. Neurologic symptoms related to SARS-CoV-2 have been described recently in the literature, and acute cerebrovascular disease is one of the most serious complications. The occurrence of large-vessel occlusion in young patients with COVID-19 infection has been exceedingly rare. In this article, we describe the profile of patients undergoing decompressive craniectomy for the treatment of intracranial hypertension by stroke associated with COVID-19 published so far. A narrative review of the central issue in focus was designed: decompressive craniectomy in a pandemic time.
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Introducción. El edema cerebral (EC) es la complicación más grave de la cetoacidosis diabética (CAD) en niños. La patogénesis del EC no se conoce con exactitud y su aparición ha sido relacionada con la terapia de rehidratación endovenosa en el tratamiento inicial.Objetivos. Estimar la prevalencia de EC en pacientes con CAD tratados en el Hospital General de Niños Pedro de Elizalde mediante rehidratación endovenosa y analizar potenciales factores de riesgo para el desarrollo de EC.Materiales y método. Estudio de diseño transversal para prevalencia y un análisis exploratorio para comparar las características clínicas y de laboratorio entre los pacientes con y sin EC. Se incluyeron pacientes de 1 a 18 años hospitalizados con diagnóstico de CAD desde el 1 de enero de 2005 hasta el 31 de diciembre de 2014.Resultados. Se analizaron 693 episodios de CAD en 561 historias clínicas. En 10 pacientes, se evidenció EC (el 1,44 %; intervalo de confianza del 95 %: 0,8-2,6). Los pacientes con EC presentaron mayor uremia (p < 0,001), menor presión de dióxido de carbono (p < 0,001) y menor natremia (p < 0,001) que aquellos pacientes sin EC.Conclusión. La prevalencia de EC en pacientes con CAD fue del 1,44 %, menor que la reportada en nuestro país (del 1,8 %). Los factores de riesgo al ingresar asociados a su desarrollo fueron la presencia de uremia elevada, hiponatremia e hipocapnia.
Introduction. Cerebral edema (CE) is the most severe complication of diabetic ketoacidosis (DKA) in children. There is no accurate knowledge of CE pathogenesis and its onset has been related to intravenous rehydration therapy during the initial treatment.Objectives. To estimate the prevalence of CE among DKA patients treated at Hospital General de Niños Pedro de Elizalde with intravenous rehydration and analyze potential risk factors for the development of CE.Materials and methods. Cross-sectional prevalence study and exploratory analysis to compare clinical and laboratory characteristics between patients with and without CE. Patients aged 1-18 years hospitalized with the diagnosis of DKA between January 1st, 2005 and December 31st, 2014 were included.Results. A total of 693 DKA events from 561 medical records were analyzed. Ten patients had evidence of CE (1.44 %; 95 % confidence interval: 0.8-2.6). Patients with CE had higher serum urea levels (p < 0.001), lower carbon dioxide pressure (p < 0.001), and lower serum sodium levels (p < 0.001) than those without CE.Conclusion. The prevalence of CE among DKA patients was 1.44 %, smaller than that reported in our country (1.8 %). The risk factors at admission associated with CE development were high serum urea levels, hyponatremia, and hypocapnia.
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Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Edema Encefálico , Cetoacidose Diabética/complicações , Prevalência , Estudos Transversais , Fatores de Risco , Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/terapiaRESUMO
Introduction: Cerebral edema (CE) is the most severe complication of diabetic ketoacidosis (DKA) in children. There is no accurate knowledge of CE pathogenesis and its onset has been related to intravenous rehydration therapy during the initial treatment. Objectives: To estimate the prevalence of CE among DKA patients treated at Hospital General de Niños Pedro de Elizalde with intravenous rehydration and analyze potential risk factors for the development of CE. Materials and methods: Cross-sectional prevalence study and exploratory analysis to compare clinical and laboratory characteristics between patients with and without CE. Patients aged 1-18 years hospitalized with the diagnosis of DKA between January 1st, 2005 and December 31st, 2014 were included. Results: A total of 693 DKA events from 561 medical records were analyzed. Ten patients had evidence of CE (1.44 %; 95 % confidence interval: 0.8-2.6). Patients with CE had higher serum urea levels (p < 0.001), lower carbon dioxide pressure (p < 0.001), and lower serum sodium levels (p < 0.001) than those without CE. Conclusion: The prevalence of CE among DKA patients was 1.44 %, smaller than that reported in our country (1.8 %). The risk factors at admission associated with CE development were high serum urea levels, hyponatremia, and hypocapnia.
Introducción. El edema cerebral (EC) es la complicación más grave de la cetoacidosis diabética (CAD) en niños. La patogénesis del EC no se conoce con exactitud y su aparición ha sido relacionada con la terapia de rehidratación endovenosa en el tratamiento inicial. Objetivos. Estimar la prevalencia de EC en pacientes con CAD tratados en el Hospital General de Niños Pedro de Elizalde mediante rehidratación endovenosa y analizar potenciales factores de riesgo para el desarrollo de EC. Materiales y método. Estudio de diseño transversal para prevalencia y un análisis exploratorio para comparar las características clínicas y de laboratorio entre los pacientes con y sin EC. Se incluyeron pacientes de 1 a 18 años hospitalizados con diagnóstico de CAD desde el 1 de enero de 2005 hasta el 31 de diciembre de 2014. Resultados. Se analizaron 693 episodios de CAD en 561 historias clínicas. En 10 pacientes, se evidenció EC (el 1,44 %; intervalo de confianza del 95 %: 0,8-2,6). Los pacientes con EC presentaron mayor uremia (p < 0,001), menor presión de dióxido de carbono (p < 0,001) y menor natremia (p < 0,001) que aquellos pacientes sin EC. Conclusión. La prevalencia de EC en pacientes con CAD fue del 1,44 %, menor que la reportada en nuestro país (del 1,8 %). Los factores de riesgo al ingresar asociados a su desarrollo fueron la presencia de uremia elevada, hiponatremia e hipocapnia.
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Edema Encefálico/etiologia , Cetoacidose Diabética/complicações , Hidratação/efeitos adversos , Adolescente , Argentina , Edema Encefálico/epidemiologia , Criança , Pré-Escolar , Estudos Transversais , Cetoacidose Diabética/epidemiologia , Cetoacidose Diabética/terapia , Feminino , Hidratação/métodos , Humanos , Hipocapnia/epidemiologia , Hiponatremia/epidemiologia , Lactente , Masculino , Prevalência , Fatores de Risco , Ureia/sangueRESUMO
Se describen las respuestas fisiológicas que el ser humano desarrolla en respuesta a la exposición a la altitud geográfica. Se describen no sólo las alteraciones debidas a una mala coordinación de los ajustes fisiológicos desencadenados durante la aclimatación a la altura sino también sus manifestaciones clínicas más relevantes. Se detallan los mecanismos moleculares subyacentes a tales respuestas y cómo su mejor conocimiento puede permitir aplicar la exposición intermitente a hipoxia como una herramienta útil para la resolución o alivio de determinadas alteraciones y patologías.
We depict the physiological responses developed by the human body in response to the exposure to geographic altitude. The main alterations due to a noncoordinated setup of the physiological adjustments triggered during the acclimatization at altitude are also described, as its most relevant clinical manifestations. The molecular mechanisms underlying such responses are detailed, and how a better knowledge of these processes can allow us to apply intermittent exposure to hypoxia programs as a useful tool for the resolution or relief of certain disorders and pathologies.
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Humanos , Adaptação Fisiológica , Altitude , Doença da Altitude , Edema Encefálico , Aclimatação , HipóxiaRESUMO
Se presenta el caso clínico e histopatológico de una lactante menor atendida en el Hospital San Jerónimo, de Montería, Colombia, con una enfermedad fulminante caracterizada por vómitos, encefalopatía, hipoglucemia, alargamiento del TP, desequilibrio hidroelectrolítico, in ltración grasa del hígado y edema cerebral, compatible con síndrome de Reye.
We present the clinical and histopathological case of an infant attended at the San Jerónimo Hospital in Montería, Colombia, with a fulminating disease characterized by vomiting, encephalopathy, hypoglycemia, PT elongation, electrolyte imbalance, fatty in ltration of the liver and cerebral edema, compatible with Reye syndrome.
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Resumen: Objetivo: Presentar la experiencia relacionada a hipotermia terapéutica controlada en pacientes graves que presentaron lesión neurológica aguda. Material y métodos: Estudio clínico, retrospectivo, observacional y descriptivo, en el Departamento de Medicina Crítica de Adultos de un Hospital de Tercer Nivel en un periodo comprendido del 01 de enero de 2016 al 31 de julio de 2017. Pacientes llevados a hipotermia terapéutica. Resultados: Cinco pacientes incluidos en el estudio, con una media de edad de 52.4 años, 80% con padecimientos neurocríticos. El promedio de estancia en la UCI fue de 15.2 días, y de hospitalización 63 días. La media de días de ventilación mecánica fue de 13.8 días. Sesenta porciento de los pacientes desarrolló neumonía asociada a la ventilación mecánica. Cuarenta porciento de los pacientes presentó una discapacidad grave. Conclusiones: La hipotermia terapéutica en el grupo estudiado no impactó de manera positiva en los desenlaces neurológicos. La complicación más frecuente fue la neumonía asociada a la ventilación mecánica.
Abstract: Objective: To present the experience related to controlled therapeutic hypothermia in severe patients who presented acute neurological injury. Material and methods: Clinical, retrospective, observational and descriptive study in the Department of Critical Care of Adults of a Hospital of Third Level in a period between January 1, 2016 and July 31, 2017. Patients taken to therapeutic hypothermia. Results: Five patients included in the study, with a mean age of 52.4 years, 80% with neurocritical conditions. The average stay in the ICU was 15.2 days, and hospitalization was 63 days. The mean number of days of mechanical ventilation was 13.8 days. Sixty percent of patients developed ventilator-associated pneumonia. Forty percent of the patients had a severe disability. Conclusions: Therapeutic hypothermia in the study group did not positively impact neurological outcomes. The most frequent complication was ventilator-associated pneumonia.
Resumo: Objetivo: Apresentar a experiência relacionada à hipotermia terapêutica controlada em pacientes graves que apresentaram lesão neurológica aguda. Material e métodos: Estudo clínico, retrospectivo, observacional e descritivo, no Departamento de Medicina Crítica de adultos, no período de 1 de janeiro de 2016 a 31 de julho de 2017. Pacientes submetidos à Hipotermia Terapêutica. Resultados: Foram incluídos no estudo 5 pacientes com idade média de 52.4 anos, 80% com alterações neurológicas. A permanência média na UTI foi de 15.2 dias e de hospitalização 63 dias. A média de dias de ventilação mecânica foi de 13.8. 60% dos pacientes desenvolveram pneumonia associada à ventilação mecânica. 40% dos pacientes tinham um incapacidade grave. Conclusões: A hipotermia terapêutica no grupo estudado não teve impacto positivo nos desfechos neurológicos. A complicação mais frequente foi pneumonia associada à ventilação mecânica.
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INTRODUCCIÓN: La cetoacidosis (CAD) es la principal causa de morbimortalidad en niños con diabetes mellitus tipo 1 (DM1) debido a las alteraciones bioquímicas asociadas, siendo el más temido el edema cerebral, con altas tasas de mortalidad y secuelas neurológicas a largo plazo. OBJETIVO: caracterizar el perfil clínico y las complicaciones de pacientes con CAD ingresados en una unidad de paciente crítico pediátrico. PACIENTES Y MÉTODO: Revisión retrospectiva de pacientes con CAD atendidos en el Hospital Clínico de la Pontificia Universidad Católica de Chile (UPCPUC) entre los años 2000 y 2015. Se evaluaron características demográficas, manifestaciones clínicas, alteraciones bioquímicas, tratamiento, complicaciones y pronóstico. Se compararon pacientes con debut de DM1 versus diabéticos conocidos, analizándose variables según distribución. RESULTADOS: Se identificaron 46 episodios de CAD. El 67% de éstos correspondió a un debut de DM1. El 66% de los diabéticos conocidos ingresaron por mala adherencia al tratamiento. Los principales síntomas de presentación fueron: 63% polidipsia, 56% poliuria, 48% vómitos, 39% pérdida de peso y 35% dolor abdominal, con medias de Glicemia 522 mg/dL, pH 7,17 y osmolaridad plasmática 305 mOsm/L. El 89% recibió insulina en infusión. El 37% presentó hipokalemia. No se registraron episodios de edema cerebral ni muertes. CONCLUSIONES: La mayoría de los ingresos por CAD correspondió a debut de DM1. En el grupo de diabéticos conocidos, la mala adherencia al tratamiento fue la principal causa de descompensación. No se presentaron complicaciones graves ni muertes asociadas al manejo de la CAD durante el período estudiado. El diagnóstico precoz y el tratamiento adecuado y estandarizado pudieran contribuir a reducir la morbilidad y mortalidad en niños con CAD.
INTRODUCTION: Diabetic ketoacidosis (DKA) is the main cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM) due to clinical and biochemical alterations associated, cerebral edema as one of the most critical because of the high mortality rates and long-term neurological se quelae. OBJECTIVE: To analyze the clinical characteristics and complications of patients with DKA ad mitted to a pediatric intensive care unit. PATIENTS AND METHODS: Retrospective study of DKA patients treated at the Hospital Clínico, Pontificia Universidad Católica de Chile (UPCPUC) between 2000 and 2015. Demographic characteristics, clinical manifestations, biochemical alterations, treatment, complications, and prognosis were assessed. Patients with T1DM onset were compared with those patients already diagnosed with diabetes, analyzing variables according to distribution. RESULTS: 46 DKA events were identified, 67% of them were the first episode of DKA. 66% of patients already diagnosed with diabetes were admitted due to poor adherence to treatment. The main symptoms described were: 63% polydipsia, 56% polyuria, 48% vomiting, 39% weight loss and 35% abdominal pain, and mean blood sugar levels of 522 mg/dL, pH 7.17, and plasma osmolality of 305 mOsm/L. 89% of patients received insulin infusion, and 37% presented hypokalemia. No episodes of cerebral edema or deaths were registered. CONCLUSIONS: Most of the DKA admissions were due to T1DM onset. In the group of patients already diagnosed with diabetes, the poor adherence to treatment was the main cause of decompensation. There were no serious complications or deaths associated with DKA management during the studied period. Early diagnosis and proper and standardized treatment contributed to reducing morbidity and mortality in children with DKA.
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Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Cetoacidose Diabética/diagnóstico , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento , Cetoacidose Diabética/etiologia , Cetoacidose Diabética/fisiopatologia , Cetoacidose Diabética/terapia , Diabetes Mellitus Tipo 1/complicações , Unidades de Terapia IntensivaRESUMO
Maple syrup urine disease (MSUD) is an inborn error of metabolism that causes elevated leucine in the setting of acute illnesses. We describe an 8-year-old boy with MSUD who developed acute pancreatitis and subsequent leucinosis. This case highlights the complexities of fluid management in patients with MSUD.
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Doença da Urina de Xarope de Bordo/complicações , Doença da Urina de Xarope de Bordo/terapia , Pancreatite/etiologia , Pancreatite/terapia , Criança , Humanos , Masculino , Doença da Urina de Xarope de Bordo/diagnóstico , Pancreatite/diagnósticoRESUMO
Resumen: Los esteroides se han usado desde 1960 y, aunque están vinculados a efectos secundarios potenciales, desempeñan un papel decisivo en el tratamiento del edema cerebral asociado con tumores cerebrales de origen primario o secundario. Por otro lado, los esteroides juegan un rol de suma importancia dentro del manejo inicial, considerando que la mayoría de los tumores desencadena edema vasogénico. Presentamos el caso de una mujer de 48 años de edad con desviación de la comisura labial, hemiparesia hemicorporal izquierda y somnolencia secundarias a tumoración temporal derecha; fue tratada con 8 mg de dexametasona intravenosa cada ocho horas, con mejoría de sus signos y síntomas (reversión de la hemiparesia fasciocorporal izquierda y mejoría del estado de conciencia). Debido a sus propiedades farmacológicas, la dexametasona se considera el esteroide de elección para el tratamiento del edema cerebral peritumoral, tiene un mínimo efecto mineralocorticoide, alta potencia y una vida media más prolongada que el resto, aunque cualquier otro esteroide podría ser eficaz si se administra en dosis equivalentes. Actualmente, no se tiene definida la dosis, el tiempo de tratamiento y el esquema de reducción ideal respecto al uso de dexametasona en el paciente con edema cerebral peritumoral; las recomendaciones encontradas son dispares.
Abstract: Steroids have been used since 1960, and even though they are associated with potential side effects, they play a decisive role in treating cerebral edema associated with primary or secondary brain tumors. On the other hand, steroids play a very important role within the initial management, considering that most tumors trigger vasogenic edema. We present the case of a 48-year-old woman with deviation of the labial commissure, left hemicorporal hemiparesis and somnolence secondary to a right temporal tumor; she was treated with dexamethasone 8 mg intravenously every eight hours, with the improvement of signs and symptoms (reversal of left fasciocorporal hemiparesis and improvement of the state of consciousness). Due to its pharmacological properties, dexamethasone is considered the steroid of choice for the treatment of peritumoral cerebral edema; it has a minimal mineralocorticoid effect, high potency and a longer half-life than the rest, although any other steroid could be effective if administered in equivalent doses. Currently, the dose, treatment time and ideal reduction scheme regarding the use of dexamethasone in the patient with cerebral peritumoral edema have not been defined, and the recommendations found are very different.
Resumo: Os esteróides têm sido usados desde 1960, e embora eles estão associados com os efeitos colaterais potenciais desempenham um papel decisivo no tratamento do edema cerebral associado a tumores cerebrais primários ou secundários. Por outro lado, os esteróides desempenham um papel muito importante no tratamento inicial, considerando que a maioria dos tumores desencadeam edema vasogênico. Apresentamos o caso de uma mulher de 48 anos de idade, com desvio da comissura labial, hemiparesia hemicorporal esquerda e sonolência secundária à tumoração temporal direita tratada com 8 mg de dexametasona por via intravenosa a cada 8 horas com melhora dos sinais e sintomas (reversão de hemiparesia fasciocorporal esquerda e melhoria do estado de consciência). Devido a suas propriedades farmacológicas, a dexametasona é considerado o esteróide de eleição para o tratamento de edema cerebral peritumoral, tem um efeito mineralocorticóide mínimo, alta potência e uma vida média mais longa do que o resto, embora qualquer outro esteróide poderia ser eficaz se administrado em doses equivalentes. Atualmente não foram definidas a dose, o tempo de tratamento e o esquema de redução ideal em relação ao uso de dexametasona no paciente com edema cerebral peritumoral, encontrando diferentes recomendações.
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Abstract Objective: To describe the characteristics of children aged 0-14 years diagnosed with diabetic ketoacidosis and compare the following outcomes between children with prior diagnosis of type 1 diabetes mellitus and children without prior diagnosis of type 1 diabetes mellitus length of hospital stay, severity on admission, insulin dosage, time of continuous insulin use, volume of fluids infused during treatment, and complications. Methods: A retrospective descriptive study with review of medical records of patients admitted to the pediatric intensive care unit of a referral hospital from June 2013 to July 2015. The following data regarding 52 admissions were analyzed: age, sex, weight, body surface area, signs, symptoms and severity on admission, blood gas, blood glucose, glycated hemoglobin, serum osmolarity, and index of mortality. The insulin dosage, time of continuous insulin use, volume administered in the expansion phase and in the first 24 h, length of stay, and complications such as electrolyte disturbances, hypoglycemia, cerebral edema, and death were compared between the two groups. Results: Patients without a previous diagnosis of DM1 were younger at admission, with mean age of 8.4 years (p < 0.01), reported more nausea or vomiting, polydipsia and polyuria, and showed more weight loss (p < 0.01). This study also observed a higher prevalence of hypokalemia (p < 0.01) and longer hospital stay in this group. Conclusions: No differences in severity between groups were observed. The study showed that children without prior diagnosis of type 1 diabetes mellitus were younger at admission, had more hypokalemia during the course of treatment, and had greater length of hospital stay.
Resumo Objetivo: Descrever as características de pacientes até 14 anos admitidos com diagnóstico de cetoacidose diabética e comparar desfechos entre os pacientes com diabete melito tipo 1 prévio e aqueles sem diabete melito tipo 1 prévio: tempo de internação, gravidade na admissão, dose de insulina usada, tempo de insulinização contínua, volume de líquido infundido durante o tratamento e complicações. Métodos: Estudo descritivo retrospectivo com revisão de prontuários de pacientes internados na UTI pediátrica de um hospital de referência de junho de 2013 a julho de 2015. Analisamos os seguintes dados referentes a 52 internações: idade, sexo, peso, superfície corporal, sinais, sintomas, gravidade na admissão, gasometrias, glicemia, hemoglobina glicada, osmolaridade sérica e índice de mortalidade. As crianças com diabete já diagnosticado foram comparadas com aquelas sem diagnóstico prévio quanto à dose de insulina, tempo de insulinização contínua, volume infundido na fase de expansão e nas primeiras 24 horas, tempo de internação e complicações como distúrbios hidroeletrolíticos, hipoglicemia, edema cerebral e morte. Resultados: Os pacientes sem diagnóstico prévio de DM I eram mais jovens no momento da admissão, com média de 8,4 anos (p < 0,01). Relataram mais sintomas como vômitos, polidipsia e poliúria e apresentaram mais perda de peso (p < 0,01). Observamos maior prevalência de hipocalemia (p < 0,01) e maior tempo de internação no grupo acima citado. Conclusões: Não observamos diferenças quanto à gravidade entre os grupos. Pacientes diabéticos prévios eram mais jovens na admissão, apresentaram mais hipocalemia durante o tratamento e permaneceram mais tempo internados.
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Humanos , Masculino , Feminino , Recém-Nascido , Pré-Escolar , Criança , Adolescente , Cetoacidose Diabética/etiologia , Insulina/administração & dosagem , Índice de Gravidade de Doença , Brasil/epidemiologia , Unidades de Terapia Intensiva Pediátrica , Estudos Retrospectivos , Fatores Etários , Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/tratamento farmacológico , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/diagnóstico , Tempo de InternaçãoRESUMO
OBJECTIVE: To characterize regional differences in brain water distribution and content during diabetic ketoacidosis (DKA) in children and determine whether these differences correlate with regional vascular supply. STUDY DESIGN: We compared changes in brain water distribution and water content in different brain regions during DKA by analyzing magnetic resonance diffusion weighted imaging data collected during DKA and after recovery in 45 children (<18 years of age). We measured the apparent diffusion coefficient (ADC) of water in the frontal and occipital cortex, basal ganglia, thalamus, hippocampus, and medulla. Brain water content was also measured in a subset of patients. RESULTS: ADC values were elevated (suggesting vasogenic cerebral edema) in the frontal cortex, basal ganglia, thalamus, and hippocampus during DKA. In contrast, ADC values in the medulla and the occipital cortex were not increased during DKA, and ADC changes in the medulla tended to be negatively correlated with other regions. Regions supplied by the anterior/middle cerebral artery circulation had greater elevations in both ADC and brain water content during DKA compared with regions supplied by the posterior cerebral artery circulation. CONCLUSIONS: ADC changes during DKA in the brainstem contrast with those of other brain regions, and changes in both ADC and brain water content during DKA vary according to regional vascular supply. These data suggest that brainstem blood flow might possibly be reduced during DKA concurrent with hyperemia in other brain regions.
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Água Corporal/metabolismo , Encéfalo/metabolismo , Cetoacidose Diabética/metabolismo , Adolescente , Água Corporal/diagnóstico por imagem , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Criança , Imagem de Difusão por Ressonância Magnética , HumanosRESUMO
OBJECTIVE: To describe the characteristics of children aged 0-14 years diagnosed with diabetic ketoacidosis and compare the following outcomes between children with prior diagnosis of type 1 diabetes mellitus and children without prior diagnosis of type 1 diabetes mellitus length of hospital stay, severity on admission, insulin dosage, time of continuous insulin use, volume of fluids infused during treatment, and complications. METHODS: A retrospective descriptive study with review of medical records of patients admitted to the pediatric intensive care unit of a referral hospital from June 2013 to July 2015. The following data regarding 52 admissions were analyzed: age, sex, weight, body surface area, signs, symptoms and severity on admission, blood gas, blood glucose, glycated hemoglobin, serum osmolarity, and index of mortality. The insulin dosage, time of continuous insulin use, volume administered in the expansion phase and in the first 24h, length of stay, and complications such as electrolyte disturbances, hypoglycemia, cerebral edema, and death were compared between the two groups. RESULTS: Patients without a previous diagnosis of DM1 were younger at admission, with mean age of 8.4 years (p<0.01), reported more nausea or vomiting, polydipsia and polyuria, and showed more weight loss (p<0.01). This study also observed a higher prevalence of hypokalemia (p<0.01) and longer hospital stay in this group. CONCLUSIONS: No differences in severity between groups were observed. The study showed that children without prior diagnosis of type 1 diabetes mellitus were younger at admission, had more hypokalemia during the course of treatment, and had greater length of hospital stay.
Assuntos
Cetoacidose Diabética/etiologia , Insulina/administração & dosagem , Adolescente , Fatores Etários , Brasil/epidemiologia , Criança , Pré-Escolar , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/diagnóstico , Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/tratamento farmacológico , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Tempo de Internação , Masculino , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Introduction The decompressive craniectomy is a surgical strategy widely used with specific criteria to control the refractory intracranial pressure (ICP). However, it is important to warn about the presence of a postcraniectomy syndrome and analyze the risk-benefit on a long term. Case Report A 72-year-old male patient diagnosed with a subarachnoid hemorrhage secondary to the rupture of an anterior circulation aneurysm that develops vasospasm, secondary ischemia, and edema with signs of herniation that required a decompressive craniectomy on a first step. Afterwards, the aneurysm was approached and he consequently developed hydrocephaly. A ventriculoperitoneal shunt is installed, contralateral to the craniectomy, and progressive sinking of the skin flap, there is neurological deterioration and paradoxical herniation. Its association with the clinical deterioration by bronchoaspiration did not allow the cranioplasty to resolve the ICP decompensation. Conclusions The paradoxical herniation as part of the postcraniectomy syndrome is an increasingly common condition identified in adult patients with cortical atrophy, and who have also been treated with ventricular shunt systems. Timely cranioplasty represents the ideal therapeutic plan once the compromise from the mass effect has resolved to avoid complications derived from the decompressive craniectomy per se.
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Maple syrup urine disease (MSUD) is a rare metabolic disorder associated with acute and chronic brain dysfunction. This condition has been shown to lead to macroscopic cerebral alterations that are visible on imaging studies. Cerebral oedema is widely considered to be detrimental for MSUD patients; however, the mechanisms involved are still poorly understood. Therefore, we investigated whether acute administration of branched-chain amino acids (BCAA) causes cerebral oedema, modifies the Na(+),K(+)-ATPase activity, affects the permeability of the blood-brain barrier (BBB) and alters the levels of cytokines in the hippocampus and cerebral cortex of 10-day-old rats. Additionally, we investigated the influence of concomitant administration of dexamethasone on the alterations caused by BCAA. Our results showed that the animals submitted to the model of MSUD exhibited an increase in the brain water content, both in the cerebral cortex and in the hippocampus. By investigating the mechanism of cerebral oedema, we discovered an association between H-BCAA and the Na(+),K(+)-ATPase activity and the permeability of the BBB to small molecules. Moreover, the H-BCAA administration increases Il-1ß, IL-6 and TNF-α levels in the hippocampus and cerebral cortex, whereas IL-10 levels were decreased in the hippocampus. Interestingly, we showed that the administration of dexamethasone successfully reduced cerebral oedema, preventing the inhibition of Na(+),K(+)-ATPase activity, BBB breakdown and the increase in the cytokines levels. In conclusion, these findings suggest that dexamethasone can improve the acute cerebral oedema and brain injury associated with high levels of BCAA, either through a direct effect on brain capillary Na(+),K(+)-ATPase or through a generalized effect on the permeability of the BBB to all compounds.