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INTRODUCTION: Vasopressors increase arterial pressure but they may have deleterious effects on mesenteric blood flow. We aimed to evaluate the response of gut biomarkers and superior mesenteric blood flow to different vasopressors with and without dobutamine. MATERIAL AND METHODS: Thirty New Zealand rabbits were included and randomly allocated to 5 groups: group A - sham group; group B - norepinephrine; group C - norepinephrine plus dobutamine; group D - vasopressin; and group E - vasopressin plus dobutamine. Mean arterial pressure (MAP) target was greater than 60 mmHg. Endotoxic shock was induced by intra-venous injection of lipopolysaccharide (LPS) in four of the five groups. Aortic blood flow (Qao), superior mesenteric artery flow (QSMA) and lactate were measured after LPS injection. Enterocyte damage was evaluated by measurements of serum citrulline and intestinal fatty acid-binding protein (I-FABP) after 4 h. RESULTS: The largest reduction in Qao occurred in group D (64 ± 17.3 to 38 ± 7.5 mL min-1; P = 0.04). QSMA also declined significantly in groups D and E and remained lower than in the other groups over 4 h (group D - baseline: 65 ± 31; 1 h: 37 ± 10; 2 h: 38 ± 10; 3 h: 46 ± 26; and 4 h: 48 ± 15 mL min-1; P < 0.005; group E - baseline: 73 ± 14; 1 h: 28 ± 4.0; 2 h: 37 ± 6.4; 3 h: 40 ± 11; and 4 h: 48 ± 11; P < 0.005; all in mL min-1). Serum citrulline was significantly lower in groups D (P = 0.014) and E (P = 0.019) in comparison to group A. The fluid administration regimen was similar in all groups. CONCLUSIONS: Vasopressin seems to negatively impact gut enterocyte function during endotoxic shock despite the association of an inodilator and adequate fluid replacement.
Assuntos
Dobutamina , Choque Séptico , Animais , Citrulina , Dobutamina/farmacologia , Dobutamina/uso terapêutico , Hemodinâmica , Humanos , Lipopolissacarídeos/farmacologia , Norepinefrina/farmacologia , Coelhos , Choque Séptico/tratamento farmacológico , Vasoconstritores/farmacologia , Vasopressinas/farmacologiaRESUMO
The objective of this review was to evalúate the efficacy of the use of vasoactive drugs in the initial resuscitation of hemorrhagic shock in animals. The search was developed using the databases: Cochrane Central Register of Controlled Trials, PUBMED, MEDLINE, EMBASE, the database was also included: Clinical Trial.gov; no date restriction of publication or language. We included randomized controlled clinical trials in animals that compared the use of vasoactive drugs with any other resuscitation strategy for hemorrhagic shock. The analysis was developed using of review manager version 5.4, with the random effects model and the Mantel Haenszel method for dichotomous data. Statistical heterogeneity was evaluated with the statisgraph I. The strength of evidence was assessed for each outcome according to the statements of the working group for the classification of the quality of the evidence (GRADE). 18 trials (n = 533 participant) were included in this meta-analysis. Compared with control, vasopressors were associated with lower relative risk of mortality during initial resuscitation from hae- morrhagic shock, with an overall risk estimate of 0.53 (0.39, 0.71) 95% confidence interval. There is evidence of the efficacy of vasopressors in resuscitation hemorrhagic shock in animals, this is of moderate to low quality; Therefore, it is necessary to develop and implement randomized clinical trials that allow an evaluation of the efficacy and safety of these drugs in humans for their use systematically in patients with hemorrhagic shock.
El objetivo de esta revisión fue evaluar la eficacia del uso de drogas vasoactivas en la resucitación inicial del hemorrágico en animales. La búsqueda fue desarrollada usando las bases de datos: Cochrane Central Register of Controlled Trials, PUBMED, MEDLINE, EMBASE, fue incluida además la base de datos: Clinical Trial.gov; sin restricción por fecha de publicación o idioma. Se incluyeron ensayos clínicos controlados y aleatorizados en animales que compararon el uso de drogas vasoactivas con cualquier otra estrategia de resucitación del hemorrágico. El análisis fue desarrollado con el uso de review manager versión 5.4, con el modelo de efectos aleatorios y el método de Mantel Haenszel para datos dicotómicos. Heterogeneidad estadística fue evaluada con el estadígrafo I. La fuerza de la evidencia fue evaluada para cada resultado acorde a las declaraciones del grupo de trabajo para la clasificación de la calidad de la evidencia (GRADE). 18 ensayos (n = 533 participante) fueron incluidos en este metaanálisis. Comparado con el control, los vasopresores fueron asociados con menor riesgo relativo de mortalidad durante la reanimación inicial del hemorrágico, con una estimación global del riesgo de 0,53 (0,39, 0,71) intervalo de confianza de 95%. Existe evidencia de la eficacia de los vasopresores en la reanimación inicial del hemorrágico en animales, esta es de calidad moderada a baja; por lo que, es necesario desarrollar e implementar ensayos clínicos aleatorizados que permitan una evaluación de la eficacia y seguridad de estas drogas en humanos para su uso de manera sistemática en pacientes con hemorrágico.
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Animais , Ressuscitação/métodos , Choque Hemorrágico/tratamento farmacológico , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND: Current guidelines do not differentiate in the utilization of vasoactive drugs in patients with cirrhosis and acute variceal bleeding (AVB) depending on liver disease severity. MATERIAL AND METHODS: In this retrospective study, clinical outcomes in 100 patients receiving octreotide plus endoscopic therapy (ET) and 216 patients with ET alone were compared in terms of failure to control bleeding, in-hospital mortality, and transfusion requirements stratifying the results according to liver disease severity by Child-Pugh (CP) score and MELD. RESULTS: In patients with CP-A or those with MELD < 10 octreotide was not associated with a better outcome compared to ET alone in terms of hospital mortality (CP-A: 0.0 vs. 0.0%; MELD < 10: 0.0 vs. 2.9%, p = 1.00), failure to control bleeding (CP-A: 8.7 vs. 3.7%, p = 0.58; MELD < 10: 5.3 vs. 4.3%, p = 1.00) and need for transfusion (CP-A: 39.1 vs. 61.1%, p = 0.09; MELD < 10: 63.2 vs. 62.9%, p = 1.00). Those with severe liver dysfunction in the octreotide group showed better outcomes compared to the non-octreotide group in terms of hospital mortality (CP-B/C: 3.9 vs. 13.0%, p = 0.04; MELD ≥ 10: 3.9 vs. 13.3%, p = 0.03) and need for transfusion (CP-B/C: 58.4 vs. 71.6%, p = 0.05; MELD ≥ 10: 50.6 vs. 72.7%, p < 0.01). In multivariate analysis, octreotide was independently associated with in-hospital mortality (p = 0.028) and need for transfusion (p = 0.008) only in patients with severe liver dysfunction (CP-B/C or MELD ≥ 10). CONCLUSION: Patients with cirrhosis and AVB categorized as CP-A or MELD < 10 had similar clinical outcomes during hospitalization whether or not they received octreotide.
Assuntos
Varizes Esofágicas e Gástricas/tratamento farmacológico , Varizes Esofágicas e Gástricas/etiologia , Fármacos Gastrointestinais/uso terapêutico , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia Gastrointestinal/etiologia , Hipertensão Portal/etiologia , Cirrose Hepática/complicações , Octreotida/uso terapêutico , Adulto , Idoso , Transfusão de Sangue , Terapia Combinada , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Fármacos Gastrointestinais/efeitos adversos , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/mortalidade , Hemostase Endoscópica , Mortalidade Hospitalar , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/mortalidade , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Testes de Função Hepática , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Octreotida/efeitos adversos , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
Objetivo avaliar o conhecimento da equipe de enfermagem sobre a administração de drogas vasoativas. Método estudo descritivo, transversal e quantitativo, realizado com 119 profissionais de enfermagem em sete unidades de terapia intensiva. Para a coleta de dados, foi utilizada uma ficha para caracterização da amostra e foi desenvolvido um instrumento contendo 14 questões de múltipla escolha que avaliavam o conhecimento sobre o preparo, a instalação e a manutenção da infusão das drogas vasoativas. O instrumento foi aplicado nos meses de junho e julho de 2015. Na análise das médias das respostas obtidas nas avaliações, foi considerada satisfatória uma nota igual ou superior a 5,0. Resultados as médias foram de 6,6 (dp ±1,6) para os auxiliares de enfermagem, 6,7 (dp ± 1,6) para os técnicos de enfermagem e 7,8 (dp ± 1,0) para os enfermeiros. Conclusão a equipe de enfermagem das unidades estudadas possui conhecimento sobre a administração de drogas vasoativas.
Objetivo evaluar el conocimiento del equipo de enfermería sobre la administración de drogas vaso-activas. Método estudio descriptivo, transversal y cuantitativo, realizado con 119 profesionales de enfermería en siete unidades de terapia intensiva. Para la recolección de datos, fue utilizada una ficha para caracterización de la muestra y fue desarrollado un instrumento conteniendo 14 preguntas de múltiple elección que evaluaban el conocimiento sobre la preparación, la instalación y la manutención de la infusión de las drogas vaso-activas. El instrumento fue aplicado en los meses de junio y julio de 2015. En el análisis de las medias de las respuestas obtenidas en las evaluaciones, fue considerada satisfactoria una nota igual o superior a 5,0. Resultados las medias fueron de 6,6 (dp ±1,6) para los auxiliares de enfermería, 6,7 (dp ± 1,6) para los técnicos de enfermería y 7,8 (dp ± 1,0) para los enfermeros. Conclusión el equipo de enfermería de las unidades estudiadas posee conocimiento sobre la administración de drogas vaso-activas.
Objective to evaluate the knowledge of the nursing team about the administration of vasoactive drugs. Method descriptive, cross-sectional and quantitative study, carried out with 119 nursing professionals in seven intensive care units. A sample characterization card was used to collect data, and an instrument with 14 multiple-choice questions was developed to evaluate the knowledge about the preparation, installation and maintenance of vasoactive drug infusion. The instrument was applied in the months of June and July of 2015. In the analysis of the means of the answers obtained in the evaluations, a score equal or superior to 5.0 was considered satisfactory. Results the averages were 6.6 (± 1.6 SD) for nursing assistants, 6.7 (± 1.6 SD) for nursing technicians and 7.8 (± 1.0 SD) for nurses. Conclusion the nursing team of the studied units has knowledge about the administration of vasoactive drugs.
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Humanos , Competência Profissional , Vasodilatadores/administração & dosagem , Equipe de Enfermagem , Conhecimento , Estudo de Validação , Unidades de Terapia IntensivaRESUMO
La paciente obstétrica en estado crítico por determinadas afecciones, pueden ser tratadas con drogas vasoactivas y demandan una atención especial por parte del obstetra. Con esta revisión bibliográfica se persiguió dar a conocer las entidades clínicas que requieren la administración de estas drogas en obstetricia, entre ellas: el embolismo del líquido amniótico, el choque séptico, el tromboembolismo pulmonar y las pérdidas de sangre, con persistencia de la inestabilidad hemodinámica después de la reposición adecuada de volumen. Igualmente, se revisan las dosis y los efectos deseados de cada medicamento, según los receptores que estimula y sus posibles efectos detrimentales. La paciente en estado crítico puede presentarse en cualquier institución hospitalaria y, en muchos casos por la urgencia de la situación, puede ser necesario el empleo de las drogas vasoactivas fuera de las unidades de cuidados intensivos, por lo que es necesidad de los obstetras estar a la altura de tales conocimientos.
The obstetric patient in critical state due to certain disorders can be treated with vasoactive drugs and demands a special care by the obstetrician. With this literature review the aim was to make known the clinical entities which require the administration of these drugs in obstetrics, among them: embolism of the amniotic fluid, the septic shock, the lung thromboembolism and blood loss, with persistence of the hemodynamic unsteadiness after the appropriate replacement of volume. Equally, the doses are checked as well as the effect of each medication, according to the receptors they stimulate and their possible harmful reactions. The patient in critical state can attend any hospital institution and, in many cases due to the emergency of the situation, it can be necessary the use of the vasoactive substances outside of the intensive care units, so it is necessary that the obstetricians get to know such knowledge.
Assuntos
Dopamina , Norepinefrina , Dobutamina , Atenção Secundária à Saúde , Estado Terminal , GestantesRESUMO
One of the most relevant complications of portal hypertension in cirrhosis is the development of gastroesophageal varices. They are present in 50 percent of patients with cirrhosis at the diagnosis. The risk of bleeding depends on the degree of portal hypertension and the severity of liver disease. Variceal hemorrhage is the most common lethal complication of cirrhosis. In the last decades there had been numerous clinical trials involving different treatment options for variceal bleeding (pharmacological, endoscopic and surgery) trying to establish the best treatment strategy. Since the rise in portal pressure is the cause of variceal rupture, therapies that can decrease portal pressure have a theoretical rationale for their use. Endoscopic treatment, although effective, has no effect on portal pressure. Vasoactive agents (vasopressin and its analogue terlipressin, somatostatin and its analogue octreotide) cause splanchnic vasoconstriction and decrease portal pressure. Pharmacological treatments have the advantage that they can be easily administered, and started as soon as the diagnosis of variceal bleeding is suspected. This makes pharmacological treatment especially attractive for centers that have no chance of emergency endoscopy. At this moment there is sufficient evidence to recommend combined treatment with vasoactive drugs and endoscopy for the control of variceal hemorrhage.
Una de las principales complicaciones de los pacientes cirróticos con hipertensión portal es el desarrollo de várices gastroesofágicas. Éstas están presentes al momento del diagnóstico en alrededor de 50 por ciento de los pacientes con cirrosis. La hemorragia variceal es la complicación letal más frecuente en los pacientes cirróticos. En las últimas décadas se han realizado múltiples esfuerzos para lograr definir la mejor combinación de técnicas (endoscópicas, farmacológicas y quirúrgicas) para disminuir la morbimortalidad asociada a la hemorragia variceal. Dado que la causa de la ruptura de las várices es un aumento de la presión portal, todas las medidas que logren disminuirla son medidas racionales para lograr detener la hemorragia. El tratamiento endoscópico, si bien efectivo, no afecta la fisiopatología de la hemorragia variceal. Las drogas vasoconstrictoras (vasopresina y su derivado terlipresina o somatostatina y su derivado octreotide) actúan a nivel de la circulación esplácnica, disminuyendo el flujo sanguíneo. El tratamiento farmacológico tiene la ventaja de ser fácilmente administrado, incluso antes de realizar una endoscopia, toda vez que se sospecha una hemorragia variceal, lo que hace particularmente atractivo su uso en centros en que no se cuenta con endoscopia de urgencia. Actualmente, existe suficiente evidencia para recomendar el uso de estos fármacos como terapia adicional a la endoscopia ante la sospecha de una hemorragia variceal.
Assuntos
Humanos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/tratamento farmacológico , Varizes Esofágicas e Gástricas/complicações , Vasoconstritores/uso terapêutico , Hipertensão Portal/complicações , Lipressina/análogos & derivados , Lipressina/uso terapêutico , Seleção de Pacientes , Vasopressinas/uso terapêuticoRESUMO
OBJETIVO: Determinar a frequência de insuficiência adrenal em crianças com diagnóstico de sepse internadas em unidades de terapia intensiva pediátrica e estabelecer a associação entre a função adrenal e a necessidade e tempo de utilização de drogas vasoativas, tempo de ventilação mecânica e mortalidade. MÉTODOS: Estudo de coorte destinado a avaliar a incidência de insuficiência adrenal em crianças com idade de 29 dias a 12 anos e diagnóstico de sepse por meio do teste de estímulo com ACTH. RESULTADOS: Foram incluídas 39 crianças no estudo. A freqüência de insuficiência adrenal foi de 30,7 por cento, totalizando 12 pacientes. Observou-se maior necessidade de drogas vasoativas, bem como no tempo de ventilação mecânica em crianças com insuficiência adrenal, porém sem significância estatística. A curva de Kaplan-Meyer mostrou menor sobrevivência no grupo de crianças com insuficiência adrenal, sem significância estatística (p = 0,1263). Não houve diferenças entre os grupos com e sem insuficiência adrenal quando avaliados tempo de ventilação mecânica, necessidade de drogas vasoativas, tipo de infecção e presença de doenças crônicas. CONCLUSÃO: O estudo determinou a frequência de insuficiência adrenal em crianças com sepse e sua relação com maior mortalidade nos primeiros 28 dias de internação. Não se encontrou significância na associação entre insuficiência adrenal e tempo de ventilação mecânica ou necessidade de drogas vasoativas.
OBJECTIVE: To determine the frequency of adrenal insufficiency in children diagnosed with sepsis that were staying in pediatric intensive care units and to establish the association between adrenal function and the use of vasoactive drugs, mechanical ventilation time and mortality. METHODS: A cohort-designed study was conducted to assess the incidence of adrenal insufficiency in children aged 29 days to 12 years who were diagnosed with sepsis using the adrenocorticotropic hormone (ACTH) stimulation test. RESULTS: Thirty-nine children were included in the study. The frequency of adrenal insufficiency was 30.7 percent (12 patients). Children with adrenal insufficiency had an increased need for vasoactive drugs as well as longer mechanical ventilation times; however, the differences were not statistically significant. A Kaplan-Meier curve indicated lower survival rates among the adrenal insufficiency children, but the differences were not statistically significant (p = 0.1263). No differences were identified between the adrenal sufficiency and adrenal insufficiency groups in regards to mechanical ventilation time, use of vasoactive drugs, infection type and chronic disease. CONCLUSION: This study determined the frequency of adrenal insufficiency in children with sepsis and its relationship to increased mortality within the first 28 post-admission days. No statistically significant association was found between adrenal insufficiency and mechanical ventilation time or the use of vasoactive drugs.
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Introducción. Desde la década de 1990, la mortalidad por el síndrome de distress respiratorio agudo ha disminuido. Sin embargo, no hay datos concluyentes acerca de que una nueva estrategia sea responsable de esta evolución (p. ej., el manejo de los fluidos). Aún no se ha dilucidado cuál es la cantidad óptima de fluidos para tratar a estos pacientes. Clásicamente la discusión se basa en estrategias liberales o conservadoras. Objetivo. El objetivo principal fue conocer cómo impacta el balance de fluidos asociado con el uso de noradrenalina en la evolución. Materiales y métodos. Se llevó a cabo un estudio observacional en 87 pacientes con síndrome de distress respiratorio agudo entre agosto y diciembre de 2007, en tres hospitales universitarios. Se utilizó el protocolo de tratamiento estándar de las Unidades de Cuidados Intensivos permitiendo la expansión en forma liberal cuando se sospechaba hipovolemia no resuelta. Resultados. Se detectaron tres situaciones de mayor riesgo y mala evolución: a) la asociación de noradrenalina y balance positivo de fluidos <2500 ml en las primeras 24 h (OR: 5,4; IC95%: 2,1-13,9; p = 0,0004), b) la asociación de noradrenalina y balance acumulativo >5500 ml en las primeras 72 h (OR: 2,7; IC95%: 1,1-6,5; p = 0,032) y c) pacientes con puntaje APACHE II >21, noradrenalina y balance positivo <2500 ml en las primeras 24 h (OR: 8,4; IC95%: 1,8-39; p = 0,008). Conclusión. La utilización de noradrenalina y escaso fluido en estrategias de reanimación que intentan "proteger" al pulmón con lesión parece no ser adecuada, según este estudio observacional(AU)
Introduction. Recent studies have shown an important decline in mortality due to acute respiratory distress syndrome since 1990. However, to date, there is no definitive evidence to demonstrate that any mode of specific therapeutic approach (i.e., fluid management) make a difference in survival or other outcome measures. The optimal fluid management of acute lung injury is not established. Classically there are two arguments: the wet or dry strategy. Objective. The main goal was to know the impact on outcome of fluid balance and the use of noradrenaline as a vasoactive drug. Materials and methods. In this observational study, 87 ventilated patients with acute respiratory distress syndrome were included from August to December 2007 in three University Critical Care Units. A standard protocol of resuscitation was used, fluid intake was liberal only in hypovolemic patients. Results. Three categories of risk and poor outcome were detected: a) noradrenaline plus positive fluid balance <2500 mL in first day (OR: 5.4; IC95%: 2.1-13.9; p = 0.0004), b) noradrenaline plus a cumulative positive balance >550 mL in first 72 hours (OR: 2.7; IC95%: 1.1-6.5; p = 0.032), c) APACHE II >21 and noradrenaline plus positive fluid balance <2500 mL in the first day (OR: 8.4; IC95%: 1.8-39; p = 0.008). Conclusion. The use of noradrenaline and conservative resuscitation with fluid in critically ill patients with acute respiratory distress syndrome in order to minimize the risk of excessive fluid therapy was associated with poor outcome and higher mortality(AU)