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ABSTRACT The desperate attempt to improve mortality, morbidity, quality of life and patient-reported outcomes in patients on hemodialysis has led to multiple attempts to improve the different modes, frequencies, and durations of dialysis sessions in the last few decades. Nothing has been more appealing than the combination of diffusion and convection in the form of hemodiafiltration. Despite the concrete evidence of better clearance of middle weight molecules and better hemodynamic stability, tangible evidence to support the universal adoption is still at a distance. Survival benefits seen in selected groups who are likely to tolerate hemodiafiltration with better vascular access and with lower comorbid burden, need to be extended to real life dialysis patients who are older than the population studied and have significantly higher comorbid burden. Technical demands of initiation hemodiafiltration, the associated costs, and the incremental benefits targeted, along with patient-reported outcomes, need to be explored further before recommending hemodiafiltration as the mode of choice.

RESUMO A tentativa desesperada de melhorar a mortalidade, morbidade, qualidade de vida e desfechos relatados pelos pacientes em indivíduos em hemodiálise levou a diversas tentativas de aprimorar os diferentes modos, frequências e durações das sessões de diálise nas últimas décadas. Nada foi mais atrativo do que a combinação de difusão e convecção na forma de hemodiafiltração. Apesar das evidências concretas de melhor depuração de moléculas de peso médio e melhor estabilidade hemodinâmica, evidências tangíveis para apoiar a adoção universal ainda estão distantes. Os benefícios de sobrevida observados em grupos selecionados que provavelmente toleram a hemodiafiltração com melhor acesso vascular e com menor carga de comorbidades precisam ser estendidos aos pacientes reais em diálise, que são mais velhos do que a população estudada e apresentam uma carga de comorbidades significativamente maior. As exigências técnicas do início da hemodiafiltração, os custos associados e os benefícios incrementais almejados, juntamente com os desfechos relatados pelos pacientes, precisam ser melhor explorados antes de se recomendar a hemodiafiltração como o modo de escolha.

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Abstract Background and objectives The Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. Methods This randomized, controlled study was conducted in a single center in the Istanbul University, Istanbul Faculty of Medicine. Forty-nine patients undergoing elective arthroscopic surgery in the BCP were recruited. In the study group, crystalloid fluid at 10 mL.kg-1 of ideal body weight was administered intravenously 30 min before the BCP for preloading. The primary outcome measures were differences of hemodynamic variables as MAP, Stroke Volume (SV), Heart Rate (HR), and Cardiac Output (CO). The secondary outcome measures were Postoperative Nausea and Vomiting (PONV) rates in postoperative first day, surgical satisfaction scale, total ephedrine dose used during surgery, and total amount of fluid. Results The MAP, CO, and SV measurements of the study group were higher than those of the control group in the 5th minute after the BCP (respectively, p= 0.001, p= 0.016, p= 0.01). The total amount of crystalloid and surgical satisfaction scales were higher in the study group (respectively, p= 0.016, p= 0.001). Total amount of colloid and ephedrine dose used in the intraoperative period, and PONV rates were lower in the study group (p= 0.003, p= 0.018, p= 0.019, respectively). Conclusion Consequently, preloading can be favorable approach to preserve hemodynamic stability.

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BACKGROUND AND OBJECTIVES: The Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. METHODS: This randomized, controlled study was conducted in a single center in the Istanbul University, Istanbul Faculty of Medicine. Forty-nine patients undergoing elective arthroscopic surgery in the BCP were recruited. In the study group, crystalloid fluid at 10...mL.kg-1 of ideal body weight was administered intravenously 30...min before the BCP for preloading. The primary outcome measures were differences of hemodynamic variables as MAP, Stroke Volume (SV), Heart Rate (HR), and Cardiac Output (CO). The secondary outcome measures were Postoperative Nausea and Vomiting (PONV) rates in postoperative first day, surgical satisfaction scale, total ephedrine dose used during surgery, and total amount of fluid. RESULTS: The MAP, CO, and SV measurements of the study group were higher than those of the control group in the 5th minute after the BCP (respectively, p...=...0.001, p...=...0.016, p...=...0.01). The total amount of crystalloid and surgical satisfaction scales were higher in the study group (respectively, p...=...0.016, p...=...0.001). Total amount of colloid and ephedrine dose used in the intraoperative period, and PONV rates were lower in the study group (p...=...0.003, p...=...0.018, p...=...0.019, respectively). CONCLUSION: Consequently, preloading can be favorable approach to preserve hemodynamic stability.

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Introducción: La craneotomía con el paciente despierto es útil para lograr resecciones cerebrales amplias de lesiones de áreas elocuentes. Objetivo: Presentar un caso al que se le realizó la técnica dormido- despierto. Método: Se realizó la inducción de la anestesia con propofol/fentanilo/rocuronio y se colocó una mascarilla laríngea. Después del bloqueo de escalpe se mantuvo la infusión de propofol/fentanilo y lidocaína hasta que se realizó la craneotomía. Se disminuyó la velocidad de infusión y se mantuvo de esta manera hasta finalizada la intervención. Resultados: Se logró el despertar del paciente a los 13 minutos de reducida la infusión. Se mantuvo buena estabilidad hemodinámica, sin depresión respiratoria ni otras complicaciones. El paciente se mantuvo colaborador, respondió preguntas y movilizó sus extremidades. No presentó complicaciones posoperatorias. Discusión: Dentro de las técnicas anestésicas utilizadas en el mundo la dormido- despierto-dormido es la más popular; sin embargo, constituye una alternativa no dormir nuevamente al paciente ni reinstrumentar la vía respiratoria. Los medicamentos más empleados son el propofol/remifentanilo, aunque la comparación con otros opioides no arrojan diferencias significativas; aunque sí supone un beneficio adicional la dexmedetomidina. Conclusiones: La craneotomía con el paciente despierto es posible de realizar en el entorno hospitalario siempre que exista un equipo multidisciplinario que consensue las mejores acciones médicas para el paciente(AU)

Introduction: Awake craniotomy is useful to achieve wide brain resections of lesions in eloquent areas. Objective: To present the case of a patient who was operated on with the asleep-awake-asleep technique. Method: Anesthesia was induced with propofol-fentanyl-rocuronium and a laryngeal mask was placed. After scalp block, the propofol-fentanyl and lidocaine infusion was maintained until craniotomy was performed. The infusion rate was decreased and remained this way until the end of the intervention. Results: The patient was awakened thirteen minutes after the infusion was reduced. Good hemodynamic stability was maintained, without respiratory depression or other complications. The patient remained collaborative, answered questions, and mobilized his limbs. He had no postoperative complications. Discussion: Among the anesthetic techniques used in the world, asleep-awake-asleep is the most popular. However, it is an alternative not to put the patient back to sleep or re-instrument the airway. The most commonly used drugs are propofol-remifentanil, although the comparison with other opioids does not show significant differences, except for dexmedetomidine, which does represent an additional benefit. Conclusions: Awake craniotomy is possible to be performed in the hospital setting as long as there is a multidisciplinary team that agrees on the best medical actions for the patient(AU)

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INTRODUCCIÓN: La hemodiafiltración en línea de alto volumen (HVHDF) es una técnica eficaz que permite la remoción de toxinas urémicas de mayor PM debido al transporte convectivo. Esta modalidad permite mayor estabilidad hemodinámica, disminución de los parámetros inflamatorios y reducción de la mortalidad cardiovascular y por todas las causas comparada con la hemodiálisis (HD). Estos beneficios se producen cuando los volúmenes de sustitución (VS) son mayores a 21 L/sesión de allí la denominación de hemodiafiltración de alto volumen. OBJETIVOS: Evaluar la eficacia de la HVHDF en comparación con HD y determinar si el cambio de modalidad se asocia a mayor estabilidad hemodinámica, mejoría en los resultados de laboratorio, en la cantidad de hospitalizaciones y en la calidad de vida. MATERIAL Y MÉTODOS: Estudio retrospectivo, observacional, en único centro que incluyó 53 pacientes, que completaron 6 meses de HVHDF luego de haber realizado al menos 6 meses de HD. Se analizaron datos demográficos, episodios de hipotensión, número y días de internación tanto en HD como en HVHDF. Se compararon: Hemoglobina (Hb), fósforo (P), parathormona intacta (PTHi), albúmina (alb), proteína C reactiva (PCR), KTV, y dosis de eritropoyetina durante el último mes de HD y sexto mes de HVHDF. Se analizó la encuesta sobre calidad de vida Kidney Disease Quality of Life-36 (KDQOL-36) al inicio y a los 6 meses de HVHDF. RESULTADOS: LA edad media fue de 60,6 años, el 67.9 % eran hombres. La FAV fue el acceso vascular en el 69.8% de los pacientes, mientras que 38 pacientes (71,1%) cumplían con volumen de sustitución > 21 litros/sesión. El 39,6 % presentó algún episodio de hipotensión en HD y 30.2 % lo hizo en HVHDF (p<0.001). El número de episodios de hipotensión fue significativamente mayor en hemodiálisis que en HVHDFL, 40 (18-68) vs 11 (3-33) (p< 0.001). El 32% de pacientes en HD requirió internación y sólo el 11% en HVHDF. Hubo mejoría significativa en la Hb: 10.7 a 11.3 (p<0.01), KTV: 1.4 a 1.5 (p<0.03) y menor requerimiento de EPO (p< 0,02) al 6° mes de HVHDF. En la encuesta de calidad de vida, KDQOL-36, se observó mejoría en el módulo, síntomas problemas, siendo estadísticamente significativo, adicionándose mejoría en short form 12 (SF) físico y mental sólo en los pacientes con volúmenes de sustitución > 21l/sesión. CONCLUSIÓN: En nuestra cohorte el cambio de HD a HVHDF se asoció a una disminución en el número de episodios de hipotensión, reflejando una mayor estabilidad hemodinámica, menor número de internaciones, una mejoría en la hemoglobina, KTV y disminución de dosis semanal de eritropoyetina

INTRODUCTION: High-volume online hemodiafiltration (HV-OL-HDF) is an effective technique to remove uremic toxins with higher molecular weight through convective transport. In correlation with hemodialysis (HD), through this method, greater hemodynamic stability, lower inflammatory parameters and a smaller risk of death due to cardiovascular or any other factors are achieved. These benefits are obtained when substitution volume (SV) is higher than 21L/session; that is the reason why the technique is called high-volume hemodiafiltration (HVHDF). OBJECTIVES: To assess the effectiveness of HVHDF as compared to HD and to determine if changing the type of therapy results in greater hemodynamic stability, better lab test results, a lower number of hospital admissions and a superior quality of life. METHODS: This retrospective observational study was conducted in only one center and included 53 patients who underwent HVHDF during 6 months after having hemodialysis (HD) for at least 6 months. We analyzed demographic variables, number of hypotension events, number of hospital admissions, and length of stay for each type of treatment. The following were compared: hemoglobin (Hb), phosphate (P), intact parathormone (iPTH), albumin (ALB), C-reactive protein (CRP), Kt/V and erythropoietin dose during the last month of HD and the sixth month of HVHDF. The Kidney Disease Quality of Life-36 (KDQOL-36™) questionnaire was completed at the beginning and after 6 months of HVHDF. RESULTS: The average age was 60.6 years old and 67.9% of the participants were men. The vascular access was created using an arteriovenous fistula in 69.8% of patients and 38 of them (71.1%) had substitution volume of > 21L/session. Some patients (39.6 %) experienced a hypotension event during HD and others (30.2%) during HVHDF (p<0.001). The number of hypotension events was significantly higher in patients treated with HD than in patients treated with HV-OL-HDF: 40 (18-68) vs. 11 (3-33) (p< 0.001). The percentage of patients admitted to hospital was the following: 32% for HD and 11% for HVHDF. A considerable improvement was observed in Hb (10.7 to 11.3 [p<0.01]) and Kt/V (1.4 to 1.5 [p<0.03]; a lower dose of EPO was needed after 6 months of HVHDF (p< 0.02). Only patients with substitution volume of > 21L/session showed statistically significant improvement in the symptoms/problems section of KDQOL-36 and in the Short Form-12 (SF-12) Physical and Mental Health Summary. CONCLUSION: When changing from HD to HVHDF, our study group had a lower number of hypotension events; greater hemodynamic stability; a smaller number of hospital admissions; better Hb levels and Kt/V, and they needed a lower dose of erythropoietin

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ABSTRACT BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2 mg/kg) and etomidate (0.3 mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p > 0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

RESUMO JUSTIFICATIVA E OBJETIVOS: A indução é uma parte crítica da prática de anestesia. Hipotensão súbita, arritmias e colapso cardiovascular são complicações ameaçadoras após a injeção de agente de indução em pacientes hemodinamicamente instáveis. É aconselhável o uso de um agente seguro com menos efeitos adversos para esse propósito. O presente estudo prospectivo, randômico, teve como objetivo comparar propofol e etomidato quanto a seus efeitos sobre a hemodinâmica e aos vários efeitos adversos em pacientes sob anestesia geral. MÉTODOS: Cem pacientes ASA I e II, entre 18-60 anos, programados para procedimento cirúrgico eletivo sob anestesia geral, foram divididos aleatoriamente em dois grupos de 50 cada para receber propofol (2 mg/kg) e etomidato (0,3 mg/kg) como um agente de indução. Os parâmetros vitais na indução, laringoscopia e posteriormente foram registrados para comparação. Efeitos adversos como dor à injeção, apneia e mioclonia foram cuidadosamente monitorados. RESULTADOS: As variáveis demográficas foram comparáveis em ambos os grupos. Os pacientes do grupo etomidato apresentaram pouca alteração da pressão arterial média (PAM) e da frequência cardíaca (FC) em comparação com o grupo propofol (p < 0,05) a partir do valor basal. Houve mais dor à injeção no grupo propofol, enquanto houve mais atividade mioclônica no grupo etomidato. CONCLUSÕES: Este estudo conclui que etomidato é um agente melhor para a indução do que o propofol em relação à estabilidade hemodinâmica e menos dor à injeção.

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BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2mg/kg) and etomidate (0.3mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p>0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

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BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2mg/kg) and etomidate (0.3mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p>0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

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O objetivo foi analisar os efeitos da prática de fisioterapia neonatal sobre os parâmetros fisiológicos freqüência cardíaca, freqüência respiratória, saturação de oxigênio, pressão arterial e temperatura axilar em recém-nascidos pré-termo submetidos à ventilação mecânica. Realizou-se um estudo prospectivo, na UTI neonatal do Hospital Municipal Universitário de São Bernardo do Campo, no período de janeiro a dezembro de 2005. Foi feita a análise descritiva das variáveis do estudo. Para comparar se os valores médios antes e depois da fisioterapia são estatisticamente diferentes foi realizado o teste Anova de medidas repetidas. E em seguida foi realizado o teste de comparações múltiplas de Newman-Keuls para as variáveis freqüência cardíaca, freqüência respiratória, saturação de oxigênio, e o teste-t pareado para as variáveis pressão arterial e temperatura axilar. O nível de significância considerado foi de 5%. A amostra foi constituída de 27 recém-nascidos pré-termo, que permaneceram sob ventilação mecânica invasiva e procedimentos intervencionistas de fisioterapia. Observou-se uma redução da freqüência cardíaca, freqüência respiratória, ao longo das sessões clínicas de fisioterapia neonatal, sem alteração da pressão arterial, aumento da saturação de hemoglobina pelo oxigênio e diminuição da temperatura porém sem repercussões clínicas. Vários fatores podem influenciar na estabilidade dos parâmetros fisiológicos, bem como na monitorização de cada um deles. Dentre eles, as características da fisiologia neonatal, os fatores ambientais e o tipo de intervenção que é realizada, ou seja, a fisioterapia adaptada à situação de cada recém-nascido, irá determinar os possíveis resultados encontrados sobre os parâmetros fisiológicos dos RNPT. Em conclusão, a fisioterapia neonatal demonstrou ser um procedimento terapêutico sem repercussões deletérias em relação à variação dos parâmetros fisiológicos para o tratamento da população estudada(AU)

The physiotherapy in the Neonatal Intensive Care Unit can be considerated a new kind of therapy. It's believed that the neonatal physiotherapeutic care is able to provide a stable heart and respiratory rate, blood pressure, and oxygen saturation, as well as maintain the corporal temperature, providing the functional maintenance of brain circulation in newborns and also of air ways with minimal turbulent flow and without lung secretion, allowing the increase on permeability and the decrease of air ways intrinsically risk factors that contribute to increase the lung resistance and decrease in physiological events of gases exchange. Other authors show injurious effects of physiotherapy regarding the neonatal population. This controversy about the neonatal respiratory physiotherapy induced to study the effects of such procedure in physiologic parameters. The objective was this paper considers the effects of neonatal physiotherapy practice on the heart and respiratory rate, arterial pressure, oxygen saturation and temperature in preterm newborn babies submitted to mechanical ventilation. A prospective study about the neonatal population of the Hospital Municipal Universit rio de S„o Bernardo do Campo, was carried out from January to December of 2005. A descriptive analysis of data was performed for the results. The Anova test, a model of variance analysis to repetitive measure, was done to compare if average values before and after the physiotherapy are statistically significant. A Newman-Keuls test was performed right away to heart and respiratory rate and oxygen saturation, and the T-test to arterial pressure and temperature. The significance level considered was 5 percent. The sample consisted of 27 preterm newborns, treated with invasive mechanical ventilation and interventionist procedures of physiotherapy. A reduction of heart and respiratory rate along the clinical sessions of neonatal physiotherapy was observed, with maintenance of ...(AU)