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The authors evaluated, retrospectively, the endoscopic sleeve gastroplasty impact in seven HIV patients, regarding effectiveness and safety outcomes. The mean baseline body mass index (BMI) was 33.76 kg/m2. The mean baseline CD4+ cell count was 690.43 cells/mm3, and the baseline viral load was undetectable. After 6 months, absolute weight loss, percentage of excess weight loss, percentage total weight loss, and BMI reduction were 20.2 ± 2.6 kg, 85.5 ± 11.1%, 21.3 ± 2.4%, and 7.1 ± 0.8 kg/m2, respectively. No patients presented severe adverse events. After 6 months, the viral load remained undetectable and the mean CD4+ cell count was 710.57 cells/mm3. The endoscopic sleeve gastroplasty is an effective and safe procedure to perform in obese HIV patients.

Orientador: Renato Giuseppe Giovanni Terzi Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas Resumo: No tratamento do choque hemorrágico de qualquer natureza, recomenda-se a rápida reposição de volume para restaurar a pressão arterial normal. Entretanto, existem evidências de que a normalização da pressão arterial,.na vigência de choque por hemorragia incontrolada, aumenta a hemorragia, a hemodiluição e a mortalidade. Realizou-se este estudo para se avaliar os efeitos imediatos e tardios de diferentes métodos de reposição volêmica durante o choque por hemorragia incontrolada. Utilizou-se um modelo experimental em ratos. Produzia-se o choque por hemorragia incontrolada pelo sangramento preliminar de 3m1/100g, seguido da amputação de 75% da cauda. O desenho experimental consistia de 3 fases: 1) a fase "pré hospitalar", na qual se produzia a hemorragia incontrolada e se avaliava a reposição volêmica objetivando pressão arterial média de 40mmHg (reposição parcial) ou de 80mmHg (reposição completa). Testou-se a reposição com Ringer com lactato, com solução de amido hidroxietílico a 6% e com sangue total; 2) a fase "hospitalar", na qual se realizava a hemostasia do ferimento e a infusão de Ringer com lactato e sangue total, para retomar a pressão arterial média para 80mmHg e o hematócrito para 30%; e 3) a fase de observação, com duração de 3 dias. Demonstrou-se que as tentativas de normalização da pressão arterial com Ringer com lactato, durante o choque por hemorragia incontrolada, provocam aumento do sangramento, hemodiluição severa e mortalidade maior e mais precoce. O uso do amido hidroxietílico somente, mesmo para manter pressão arterial média em 40mmHg, também acarretou maior hemodiluição e mortalidade. A utilização precoce de sangue no tratamento deste tipo de choque evitou a hemodiluição severa e aumentou a sobrevida tanto na reposição parcial como na completa (normotensão). Quando não houver disponibilidade imediata de sangue, a reposição parcial com cristalóide poderá resultar em maior sobrevida que a reposição objetivando pressão arterial normal Abstract: Prehospital guidelines for the treatment of hemorrhagic shock r.ecommend rapid volume resuscitation to normal blood pressure. However, there is eviderice that fluid resuscitation (FR) to normal blood pressure in the setting of uncomtrolledl hemorrhagic shock (UHS) causes increased bleeding, hemodilution and mortality. The purpose of this study was to examine the long-term effects of different FR regimens during UHS, using a outcome rat model. UHS was produced by preliminary bleed of 3ml/100g, followed by 75% tail amputation. Experimemtal design consisted of 3 phases: 1) a "prehospital phase" with UHS arnd resuscitation aimed at mean arterial pressure (MAP) of 40mmHg (hypotensive FR) or 80mmHg (normotensive FR). It was tested FR with lactated Ringer' s (LR), Hydroxyethyl-starch 6% (HES) and whole blood (WB); 2) a "hospital phase" with control of the.bleeding and continued resuscitation to MAP > 80mmHg and hematocrit near 30%; 3) a three day observation phase. This study demonstrates that attempts to achieve normal MAP with LR, during uncontrolled bleeding, increases blood loss, hemodilution arid mortality. Infusion of only HES increases bleeding, hemodilution and mortality, even in hypotensive FR. The early use of blood in the treatment of UHS, avoiding severe hemodilution, may significantly improve survival in both normotensive and hypotensive resuscitation. When blood is unavailable in the prehospital setting, "hypotensive resuscitation" with LR may offer a survival benefit Doutorado Cirurgia Doutor em Cirurgia

Objective: To investigate the impact of intensive care unit admission during medical handover on mortality. Methods: Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio. Results: A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality. Conclusion: Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study. RESUMO Objetivo: Avaliar o impacto na mortalidade da admissão em unidade de terapia intensiva durante passagem de plantão médico. Métodos: Análise post-hoc de estudo original publicado previamente, com o objetivo de avaliar os impactos da readmissão em unidade de terapia intensiva nos desfechos clínicos. Este estudo de coorte retrospectivo, em centro único, com pareamento por escore de propensão, foi conduzido em uma unidade de terapia intensiva geral, aberta, com 41 leitos. Com base no tempo de internação na unidade de terapia intensiva, os pacientes foram categorizados em duas coortes: Grupo Passagem de Plantão (admissão entre 6h30 e 7h30 ou 18h30 e 19h30) ou Grupo Controle (internação entre 7h31 e 18h29 ou 19h31 e 6h29). Pacientes no Grupo Passagem de Plantão foram pareados com Grupo Controle na proporção de 1:2. Resultados: Entre 1° de junho de 2013 e 31 de maio de 2015, 6.650 pacientes adultos foram admitidos na unidade de terapia intensiva. Após a exclusão de participantes inelegíveis, 5.779 pacientes (389; 6,7% no Grupo de Admissão na Passagem de Plantão e 5.390; 93,3% no Grupo de Controle) foram elegíveis para pareamento por escore de propensão, dos quais 1.166 foram pareados com sucesso (389; 33,4% no Grupo Passagem de Plantão e 777; 66,6% no Grupo Controle). Após pareamento, admissão na unidade de terapia intensiva durante a passagem plantão não foi associada ao aumento da chance de óbito na unidade de terapia intensiva (RC: 1,40; IC95%: 0,92-2,11; p=0,113) ou no hospital (RC: 1,23; IC95%: 0,85-1,75; p=0,265). Conclusão: Internação em unidade de terapia intensiva durante passagem de plantão médico não impactou na mortalidade hospitalar.

BACKGROUND For palliation of malignant biliary obstruction (MBO), the gold-standard method of biliary drainage is endoscopic retrograde cholangiopancreatography (ERCP) with the placement of metallic stents. Endoscopic ultrasound (EUS)-guided drainage is an alternative that is typically reserved for cases of ERCP failure. Recently, however, there have been robust randomized clinical trials (RCTs) comparing EUS-guided drainage and ERCP as primary approaches to MBO. AIM To compare EUS guidance and ERCP in terms of their effectiveness and safety in palliative biliary drainage for MBO. METHODS This was a systematic review and meta-analysis, in which we searched the MEDLINE, Excerpta Medica, and Cochrane Central Register of Controlled Trials databases. Only RCTs comparing EUS and ERCP for primary drainage of MBO were eligible. All of the studies selected provided data regarding the rates of technical and clinical success, as well as the duration of the procedure, adverse events, and stent patency. We assessed the risk of biases using the Jadad score and the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation criteria. RESULTS The database searches yielded 5920 records, from which we selected 3 RCTs involving a total of 222 patients (112 submitted to EUS and 110 submitted to ERCP). In the EUS and ERCP groups, the rate of technical success was 91.96% and 91.81%, respectively, with a risk difference (RD) of 0.00% (95%CI: -0.07, 0.07; P = 0.97; I2 = 0%). The clinical success was 84.81% and 85.53% in the EUS and ERCP groups, respectively, with an RD of −0.01% (95%CI: -0.12, 0.10; P = 0.90; I2 = 0%). The mean difference (MD) for the duration of the procedure was -0.12% (95%CI: -8.20, 7.97; P = 0.98; I2 = 84%). In the EUS and ERCP groups, there were 14 and 25 adverse events, respectively, with an RD of -0.06% (95%CI: -0.23, 0.12; P = 0.54; I2 = 77%). The MD for stent patency was 9.32% (95%CI: -4.53, 23.18; P = 0.19; I2 = 44%). The stent dysfunction rate was significantly lower in the EUS group (MD = -0.22%; 95CI:-0.35, -0.08; P = 0.001; I2 = 0%). CONCLUSION EUS represents an interesting alternative to ERCP for MBO drainage, demonstrating lower stent dysfunction rates compared with ERCP. Technical and clinical success, duration, adverse events and patency rates were similar.

Paciente de 83 anos, feminina, com acidente vascular cerebral isquêmico por obstrução da artéria cerebral média direita. Realizada trombólise intra-arterial após cinco horas de evolução com controle da hipotensão usando noradrenalina obtendo sucesso na evolução e acompanhamento. Um aumento da morbidade e mortalidade em pacientes com hipotensão tem sido relatado. O controle da hipotensão arterial em pacientes com AVC é uma das medidas importantes na fase aguda da doença para uma boa evolução.

IntroductionHandover is a process of transferring information, responsibility and authority for providing care of critically ill patients from a departing intensivist to an oncoming intensivist. The effect of i admission during a medical handover on clinical outcomes is unknown.ObjectivesOur purpose was to evaluate the impact of ICU admission during a medical handover on clinical outcomes.MethodsPost hoc analysis of a cohort study addressing the effect of ICU admissions during the handover on outcomes. This retrospective, single center, propensity matched cohort study was conducted in a 41-bed open general ICU located in a private tertiary care hospital in São Paulo, Brazil. Based on time of ICU admission, patients were categorized into two cohorts: handover group (ICU admission between 6:30 am to 7:30 or 6:30 pm to 7:30 pm) or control group (admission between 7:31 am to 6:29 pm or 7:31 pm to 6:29 am). Patients in the handover group were propensity matched to patients in the control group at 1:2 ratio. Our primary outcome was hospital mortality.ResultsBetween June 1, 2013 and May 31, 2015, 6,650 adult patients were admitted to the ICU. Following exclusion of ineligible participants, 5,779 patients [389 (6.7%) in handover group and 5390 (93.3%) in control group] were eligible for propensity score matching, of whom 1,166 were successfully matched [389 (33.4%) handover group and 777 (66.6%) in control group]. Before matching, hospital mortality was 14.1% (55/389 patients) in handover group compared to 11.7% (628/5,390) in control group (p=0.142). After propensity-score matching, ICU admission during handover was not associated with increased risk of ICU (OR, 1.40; 95% CI, 0.92 to 2.11; p=0.11) and hospital (OR, 1.23; 95%CI, 0.85 to 1.75; p=0.26) mortality. ICU and hospital length of stay did not differ between the groups.ConclusionIn this propensity-matched single center cohort study, ICU admission during medical handover did not affect clinical outcomes.

Background Elevated catecholamine levels might be associated with unfavorable outcome after traumatic brain injury (TBI). We investigated the association between catecholamine levels in the first 24 h post-trauma and functional outcome in patients with isolated moderate-to-severe TBI. Methods A cohort of 174 patients who sustained isolated blunt TBI was prospectively enrolled from three Level-1 Trauma Centers. Epinephrine (Epi) and norepinephrine (NE) concentrations were measured at admission (baseline), 6, 12 and 24 h post-injury. Outcome was assessed at 6 months by the extended Glasgow Outcome Scale (GOSE) score. Fractional polynomial plots and logistic regression models (fixed and random effects) were used to study the association between catecholamine levels and outcome. Effect size was reported as the odds ratio (OR) associated with one logarithmic change in catecholamine level. Results At 6 months, 109 patients (62.6%) had an unfavorable outcome (GOSE 5–8 vs. 1–4), including 51 deaths (29.3%). Higher admission levels of Epi were associated with a higher risk of unfavorable outcome (OR, 2.04, 95% CI: 1.31–3.18, p = 0.002) and mortality (OR, 2.86, 95% CI: 1.62–5.01, p = 0.001). Higher admission levels of NE were associated with higher risk of unfavorable outcome (OR, 1.59, 95% CI: 1.07–2.35, p = 0.022) but not mortality (OR, 1.45, 95% CI: 0.98–2.17, p = 0.07). There was no relationship between the changes in Epi levels over time and mortality or unfavorable outcome. Changes in NE levels with time were statistically associated with a higher risk of mortality, but the changes had no relation to unfavorable outcome. Conclusions Elevated circulating catecholamines, especially Epi levels on hospital admission, are independently associated with functional outcome and mortality after isolated moderate-to-severe TBI. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1620-6) contains supplementary material, which is available to authorized users.

Background Traumatic brain injury (TBI) elicits intense sympathetic nervous system (SNS) activation with profuse catecholamine secretion. The resultant hyperadrenergic state is linked to immunomodulation both within the brain and systemically. Dysregulated inflammation post-TBI exacerbates secondary brain injury and contributes to unfavorable patient outcomes including death. The aim of this study was to characterize the early dynamic profile of circulating inflammatory cytokines/chemokines in patients admitted for moderate-to-severe TBI, to examine interrelationships between these mediators and catecholamines, as well as clinical indices of injury severity and neurological outcome. Methods Blood was sampled from 166 isolated TBI patients (aged 45 ± 20.3 years; 74.7 % male) on admission, 6-, 12-, and 24-h post-injury and from healthy controls (N = 21). Plasma cytokine [interleukin (IL)-1β, -2, -4, -5, -10, -12p70, -13, tumor necrosis factor (TNF)-α, interferon (IFN)-γ] and chemokine [IL-8, eotaxin, eotaxin-3, IFN-γ-induced protein (IP)-10, monocyte chemoattractant protein (MCP)-1, -4, macrophage-derived chemokine (MDC), macrophage inflammatory protein (MIP)-1β, thymus activation regulated chemokine (TARC)] concentrations were analyzed using high-sensitivity electrochemiluminescence multiplex immunoassays. Plasma catecholamines [epinephrine (Epi), norepinephrine (NE)] were measured by immunoassay. Neurological outcome at 6 months was assessed using the extended Glasgow outcome scale (GOSE) dichotomized as good (>4) or poor (≤4) outcomes. Results Patients showed altered levels of IL-10 and all chemokines assayed relative to controls. Significant differences in a number of markers were evident between moderate and severe TBI cohorts. Elevated IL-8, IL-10, and TNF-α, as well as alterations in 8 of 9 chemokines, were associated with poor outcome at 6 months. Notably, a positive association was found between Epi and IL-1β, IL-10, Eotaxin, IL-8, and MCP-1. NE was positively associated with IL-1β, IL-10, TNF-α, eotaxin, IL-8, IP-10, and MCP-1. Conclusions Our results provide further evidence that exaggerated SNS activation acutely after isolated TBI in humans may contribute to harmful peripheral inflammatory cytokine/chemokine dysregulation. These findings are consistent with a potentially beneficial role for therapies aimed at modulating the inflammatory response and hyperadrenergic state acutely post-injury. Electronic supplementary material The online version of this article (doi:10.1186/s12974-016-0500-3) contains supplementary material, which is available to authorized users.

Purpose of review Trauma systems are central in the care of trauma patients and the concept of 'Critical Care Cascade' matches the concept of the 'Trauma Systems'. Both concepts aim to offer a model of continuum care from prehospital assistance to ICU discharge that can have a significant impact on outcome. In spite of the trauma system concept maturity, many controversies still remain unresolved. This text will review some of the relevant literature related to prehospital and early hospital care of trauma patients. Recent findings Effectiveness of trauma systems and outcome studies on prehospital and early hospital care have been published recently. Limitations, controversies and important points of those studies will be highlighted in this text. Summary Although there is a lack of definitive evidence to support many of the current recommendations for the acute care of trauma patients, the historical development of trauma systems, their long experience and even the existing controversies, can help to establish other critical pathways and can guide performance evaluations so necessary to improve outcomes.

JUSTIFICATIVA E OBJETIVOS: A contusão miocárdica está freqüentemente associada ao trauma torácico fechado. Seu correto diagnóstico é um constante desafio aos profissionais que trabalham em unidades de emergência, devido aos seus sintomas inespecíficos e a ausência de exames subsidiários com precisão para fazer o diagnóstico. Dentre os diversos métodos diagnósticos estudados, tem-se destacado nos últimos anos o papel dos indicadores de necrose miocárdica troponina I e troponina T. Por serem proteínas constituintes do aparelho de regulação contrátil celular, são liberadas na corrente sanguínea somente após a perda da integridade de membrana dos miócitos e, portanto, são altamente específicas para detectar lesão miocárdica. CONTEUDO: Foi realizada uma revisão de estudos clínicos nas bases eletrônicas de dados MedLine e LILACS, no período de janeiro de 1980 a novembro de 2006, sobre a importância da dosagem seriada de troponina como instrumento diagnóstico e preditor de evolução clínica desfavorável nos pacientes com contusão miocárdica. CONCLUSÕES: Embora exista maior especificidade das troponinas I e T quando comparadas aos indicadores tradicionais, CKMB massa e CPK total, esses dois indicadores apresentarem sensibilidade e valor preditivo positivo baixos para diagnosticar contusão miocárdica. Pacientes que apresentam alterações eletrocardiográficas, elevação de troponinas, ou ambas, devem permanecer em observação em unidade de terapia intensiva (UTI), por no mínimo 24 horas, período em que se desenvolve a maioria das complicações decorrentes da contusão miocárdica. BACKGROUND AND OBJECTIVES: Myocardial contusion is often associated with blunt chest trauma. Its diagnosis is challenging to the professionals who work in emergency department due to nonspecific symptoms and the lack of auxiliary exams with enough accuracy to diagnose. Among the available diagnostic tools, the biomarkers of myocardial injury troponin I and troponin T have stood out. Troponins are proteins of the citocellular apparatus, released into the bloodstream only after the disruption of myocytes cellular membrane. Therefore they are highly specific to detect myocardial injuries. CONTENTS: We performed a clinical review using the electronic databases MedLine and LILACS from January 1980 to November 2006 about the importance of a serial measurement of troponin I and T as a diagnostic tool as well as predictor of unfavorable clinical outcome in patients with myocardial contusion after a blunt chest trauma. CONCLUSIONS: Although troponins I and T are more specific than usual biomarkers CKMB and CK, these two first biomarkers show a low sensitivity and positive predictive value to diagnosis myocardial contusion. Patients with ECG abnormalities, troponins elevations or both should remain in an intensive care unit (ICU) for at least 24 hours, period in which they cam develop most of the complications related to myocardial contusion.

Traumatic brain injury (TBI) is the main cause of trauma-related deaths. Systemic hypotension and intracranial hypertension causes cerebral ischemia by altering metabolism of prostanoids. We describe prostanoid, pupilar and pathological response during resuscitation with hypertonic saline solution (HSS) in TBI.Method Fifteen dogs were randomized in three groups according to resuscitation after TBI (control group; lactated Ringer’s (LR) group and HSS group), with measurement of thromboxane, prostaglandin, macroscopic and microscopic pathological evaluation and pupil evaluation.Result Concentration of prostaglandin is greater in the cerebral venous blood than in plasma and the opposite happens with concentration of thromboxane. Pathology revealed edema in groups with the exception of group treated with HSS.Discussion and conclusion There is a balance between the concentrations of prostaglandin and thromboxane. HSS prevented the formation of cerebral edema macroscopically detectable. Pupillary reversal occurred earlier in HSS group than in LR group. O traumatismo cranioencefálico (TCE) é a principal causa de morte relacionada ao trauma. O choque hemorrágico e hipertensão intracraniana causam isquemia cerebral alterando o metabolismo de prostanóides. Neste estudo, relatamos o comportamento dos prostanóides, resposta pupilar e patologia durante a reposição volêmica com solução salina hipertônica (SSH) no TCE.Método Quinze cachorros foram randomizados em três grupos (controle, grupo de Ringer lactato e grupo de SSH) e foram avaliados tromboxane, prostaglandina, avaliação patológica macroscópica e microscópica e status pupilar.Resultado A concentração de prostaglandina é maior no sangue cerebral em comparação ao plasma, e o inverso ocorre com o tromboxane. A patologia revelou edema em todos os grupos, com exceção do grupo tratado com SSH.Discussão e conclusão Existe um equilíbrio entre concentrações cerebrais e plasmáticas de prostaglandina e tromboxane. A SSH protegeu o cérebro da formação de edema pós traumático.

The presence of coagulopathy is common after severe trauma. The aim of this study was to identify whether isolated severe traumatic brain injury (TBI) is an independent risk factor for coagulopathy. Prospective observational cohort of adult patients admitted to a Level I Trauma Center within 6 h of injury. Patients were categorized according to the abbreviated injury scale (AIS): Group 1-isolated severe TBI (AIS head ≥ 3 + AIS non-head

OBJETIVO: avaliar as interrelações entre as alterações hemometabólicas cerebrais e sistêmicas em pacientes com traumatismo craniencefálico (TCE) grave submetidos a um protocolo terapêutico padronizado. DESENHO: estudo prospectivo, intervencionista em pacientes com coma traumático. LOCAL: uma UTI geral em hospital universitário. PACIENTES E MÉTODOS: vinte e sete pacientes (21M e 6F), idade 14-58 anos, com TCE grave, com três a oito pontos na escala de coma de Glasgow, foram avaliados prospectivamente segundo um protocolo cumulativo padronizado para tratamento da hipertensão intracraniana aguda, o qual incluía medidas rotineiras da pressão intracraniana (PIC) e da extração cerebral de oxigênio (ECO2). Foram analisadas as interrelações hemometabólicas envolvendo: pressão arterial média (PAM), PIC, pressão parcial de gás carbônico arterial (PaCO2), ECO2, pressão de perfusão cerebral (PPC) e extração sistêmica de oxigênio (ESO2). INTERVENÇÕES: apenas as padronizadas no protocolo terapêutico. RESULTADOS: não houve correlação entre a ECO2 e a PPC (r = -0,07; p = 0,41). Houve correlação inversa entre a PaCO2 e a ECO2 (r = -0,24; p = 0,005) e direta entre a ESO2 e a ECO2 (r = 0,24; p = 0,01). A mortalidade geral dos pacientes foi de 25,9% (7/27). CONCLUSÃO: 1) a PPC não se correlaciona com a ECO2 em quaisquer níveis de PIC; 2) a ECO2 está estreitamente relacionada aos diferentes níveis de PaCO2 ; e 3) durante a hiperventilação otimizada existe um acoplamento entre a ECO2 e a ESO2. OBJECTIVE: to evaluate the interrelationships between cerebral and systemic hemometabolic alterations in patients with severe traumatic brain injury managed according to a standardized therapeutic protocol. DESIGN: prospective, interventional study in patients with traumatic coma. SETTING: a general Intensive Care Unit in a teaching hospital. PATIENTS AND METHODS: twenty-seven patients (21M e 6F), aging 14--58 years, with severe acute brain trauma, presenting with three to eight points on the Glasgow Coma Scale, were prospectively evaluated according to a cumulative protocol for the management of acute intracranial hypertension, where intracranial pressure (ICP) and cerebral extraction of oxygen (CEO2) were routinely measured. Hemometabolic interrelationships involving mean arterial pressure (MAP), ICP, arterial carbon dioxide tension (PaCO2), CEO2, cerebral perfusion pressure (CPP) and systemic extraction of oxygen (SEO2) were analyzed. INTERVENTIONS: routine therapeutic procedures. RESULTS: no correlation was found between CEO2 and CPP (r = -0.07; p = 0.41). There was a significant negative correlation between PaCO2 and CEO2 (r = -0.24; p = 0.005) and a positive correlation between SEO2 and CEO2 (r = 0.24; p = 0.01). The mortality rate in this group of patients was 25.9% (7/27). Conclusion: 1) CPP and CEO2 are unrelated; 2) CEO2 and PaCO2 are closely related; 3) during optimized hyperventilation, CEO2 and SEO2 are coupled.

OBJETIVO: avaliar as interrelações entre as alterações hemometabólicas cerebrais e sistêmicas em pacientes com traumatismo craniencefálico (TCE) grave submetidos a um protocolo terapêutico padronizado. DESENHO: estudo prospectivo, intervencionista em pacientes com coma traumático. LOCAL: uma UTI geral em hospital universitário. PACIENTES E MÉTODOS: vinte e sete pacientes (21M e 6F), idade 14-58 anos, com TCE grave, com três a oito pontos na escala de coma de Glasgow, foram avaliados prospectivamente segundo um protocolo cumulativo padronizado para tratamento da hipertensão intracraniana aguda, o qual incluía medidas rotineiras da pressão intracraniana (PIC) e da extração cerebral de oxigênio (ECO2). Foram analisadas as interrelações hemometabólicas envolvendo: pressão arterial média (PAM), PIC, pressão parcial de gás carbônico arterial (PaCO2), ECO2, pressão de perfusão cerebral (PPC) e extração sistêmica de oxigênio (ESO2). INTERVENÇÕES: apenas as padronizadas no protocolo terapêutico. RESULTADOS: não houve correlação entre a ECO2 e a PPC (r = -0,07; p = 0,41). Houve correlação inversa entre a PaCO2 e a ECO2 (r = -0,24; p = 0,005) e direta entre a ESO2 e a ECO2 (r = 0,24; p = 0,01). A mortalidade geral dos pacientes foi de 25,9% (7/27). CONCLUSÃO: 1) a PPC não se correlaciona com a ECO2 em quaisquer níveis de PIC; 2) a ECO2 está estreitamente relacionada aos diferentes níveis de PaCO2 ; e 3) durante a hiperventilação otimizada existe um acoplamento entre a ECO2 e a ESO2.

Background Calcium is one of the triggers involved in ischemic neuronal death. Because hypotension is a strong predictor of outcome in traumatic brain injury (TBI), we tested the hypothesis that early fluid resuscitation blunts calcium influx in hemorrhagic shock associated to TBI. Methods Fifteen ketamine-halothane anesthetized mongrel dogs (18.7 kg +/- 1.4 kg) underwent unilateral cryogenic brain injury. Blood was shed in 5 minutes to a target mean arterial pressure of 40 mm Hg to 45 mm Hg and maintained at these levels for 20 minutes (shed blood volume = 26 mL/kg +/- 7 mL/kg). Animals were then randomized into three groups: CT (controls, no fluid resuscitation), HS (7.5% NaCl, 4 mL/kg, in 5 minutes), and LR (lactate Ringer's, 33 mL/kg, in 15 minutes). Twenty minutes later, a craniotomy was performed and cerebral biopsies were obtained next to the lesion ("clinical penumbra") and from the corresponding contralateral side ("lesion's mirror") to determine intracellular calcium by fluorescence signals of Fura-2-loaded cells. Results Controls remained hypotensive and in a low-flow state, whereas fluid resuscitation improved hemodynamic profile. There was a significant increase in intracellular calcium in the injured hemisphere in CT (1035 nM +/- 782 nM), compared with both HS (457 nM +/- 149 nM, p = 0.028) and LR (392 nM +/- 178 nM, p = 0.017), with no differences between HS and LR (p = 0.38). Intracellular calcium at the contralateral, uninjured hemisphere was 438 nM +/- 192 nM in CT, 510 nM +/- 196 nM in HS, and 311 nM +/- 51 nM in LR, with no significant differences between them. Conclusion Both small volume hypertonic saline and large volume lactated Ringer's blunts calcium influx in early stages of TBI associated to hemorrhagic shock. No fluid resuscitation strategy promotes calcium influx and further neural damage.

Myocardial contusion is often associated with blunt chest trauma. Its diagnosis is challenging to the professionals who work in emergency department due to nonspecific symptoms and the lack of auxiliary exams with enough accuracy to diagnose. Among the available diagnostic tools, the biomarkers of myocardial injury troponin I and troponin T have stood out. Troponins are proteins of the citocellular apparatus, released into the bloodstream only after the disruption of myocytes cellular membrane. Therefore they are highly specific to detect myocardial injuries.We performed a clinical review using the electronic databases MedLine and LILACS from January 1980 to November 2006 about the importance of a serial measurement of troponin I and T as a diagnostic tool as well as predictor of unfavorable clinical outcome in patients with myocardial contusion after a blunt chest trauma.Although troponins I and T are more specific than usual biomarkers CKMB and CK, these two first biomarkers show a low sensitivity and positive predictive value to diagnosis myocardial contusion. Patients with ECG abnormalities, troponins elevations or both should remain in an intensive care unit (ICU) for at least 24 hours, period in which they cam develop most of the complications related to myocardial contusion.

therapy in juvenile systemic lupus erythematosus: prospective vali-dation of the disease activity core set. Arthritis Rheum 2005;52:2854–64.3. Bombardier C, Gladman DD, Urowitz MB, Caron D, Chang CH,and the Committee on Prognosis Studies in SLE. Derivation of theSLEDAI: a disease activity index for lupus patients. ArthritisRheum 1992;35:630–40.4. Liang MH, Socher SA, Larson MG, Schur PH. Reliability andvalidity of six systems for the clinical assessment of disease activityin systemic lupus erythematosus. Arthritis Rheum 1989;32:1107–18.5. Vitali C, Bencivelli W, Isenberg DA, Smolen JS, Snaith ML, SciutoM, et al, and The European Consensus Study Group for DiseaseActivity in SLE. Disease activity in systemic lupus erythematosus:report of the Consensus Study Group of the European Workshopfor Rheumatology Research. II. Identification of the variablesindicative of disease activity and their use in the development of anactivity score. Clin Exp Rheumatol 1992;10:541–7.6. Ruperto N, Ravelli A, Murray KJ, Lovell DJ, Andersson-Gare B,Feldman BM, et al, for the Paediatric Rheumatology InternationalTrials Organisation (PRINTO) and the Pediatric RheumatologyCollaborative Study Group (PRCSG). Preliminary core sets ofmeasures for disease activity and damage assessment in juvenilesystemic lupus erythematosus and juvenile dermatomyositis. Rheu-matology (Oxford) 2003;42:1452–9.7. Ruperto N, Ravelli A, Oliveira S, Alessio M, Mihaylova D, Pasic S,et al, for the Pediatric Rheumatology International Trials Or-ganization (PRINTO) and the Pediatric Rheumatology Collabora-tive Study Group (PRCSG). The Pediatric Rheumatology Inter-national Trials Organization/American College of Rheumatologyprovisional criteria for the evaluation of response to therapy injuvenile systemic lupus erythematosus: prospective validationof the definition of improvement. Arthritis Rheum2006;55:355–63.

The devastating effects of hypotension on head-trauma-related mortality are well known. This study evaluates the systemic and cerebral hemodynamic responses to volume replacement with 3% hypertonic saline (HSS) or lactated Ringer's solution (LR), during the acute phase of hemorrhagic shock (HS) associated with traumatic brain injury (TBI).Fifteen dogs were assigned to one of three groups (n = 5, each) according to the volume replacement protocol, infused after TBI (brain fluid percussion, 4 atm) and epidural balloon to an intracranial pressure (ICP) higher than 20 mm Hg and HS, induced by blood removal to a mean arterial pressure (MAP) of 40 mm Hg in 5 minutes: Group HS+TBI+HSS (8 mL/kg of 3% HSS), HS+TBI+LR (16 mL/kg LR), and Group HS+TBI (controls, no fluids). We simulated treatment during prehospital and early hospital admission. Groups HS+ TBI and HS+TBI+LR received shed blood infusion to a target hematocrit of 30%. Measurements included shed blood volume, fluid volume infused to restore MAP, MAP, cardiac output, cerebral perfusion pressure, cerebral and systemic lactate, and oxygen extraction ratios.Fluid replacement with HSS 3% or LR promoted major hemodynamic benefits over control animals without luids. Cerebral perfusion pressure was higher than controls and similar between treated groups; however, HSS 3% infusion was associated with lower ICP during the "early hospital phase" and a higher serum sodium and osmolarity.In the event of severe head trauma and hemorrhagic shock, the use of HSS 3% and larger volumes of LR promote similar systemic and cerebral hemodynamic benefits. However, a lower ICP was observed after HSS 3% than after LR.

Sandra Christina Pereira Lima Shiramizo,Murillo Santucci Cesar Assuncao, AndreiaPardini, Antonio Capone Neto, and EliezerSilva work in the critical care unit andAna Maria Santos works in the emergencydepartment at Hospital Israelita AlbertEinstein, Sao Paulo, Brazil.For questions related to this article, contactSandra Shiramizo at sandralima@einstein.br.

We tested the hypothesis that the combination of polymerized bovine hemoglobin (PBHg) with hypertonic saline may be beneficial for the initial management of hemorrhagic shock in 22 mongrel dogs (15 +/- 1 kg) bled to a mean arterial pressure (MAP) of 40 mm Hg in 5 min and maintained at this level for 45 min (shed blood volume approximately 50 ml/kg). Animals were treated with a 4 ml/kg bolus over 4 min of one of the following fluids: whole blood, 7.5% NaCl (HS), 13 g/dl of PBHg, or 7.5% NaCl combined with polymerized bovine hemoglobin (HS-PBHg). No additional intervention was performed, and the animals were followed for 60 min after treatment. PBHg and HS-PBHg produced a sustained, significant increase in MAP. Cardiac output was transiently increased only after HS and HS-PBHg. A partial increase in superior mesenteric artery blood flow was observed, particularly after HS-PBHg. We concluded that small volumes of PBHg alone restore MAP, but not blood flow. The combination of PBHg with hypertonic saline provides improvements in cardiac output and mesenteric blood flow, suggesting a potential benefit for the initial management of major blood loss.

to evaluate the interrelationships between cerebral and systemic hemometabolic alterations in patients with severe traumatic brain injury managed according to a standardized therapeutic protocol.prospective, interventional study in patients with traumatic coma.a general Intensive Care Unit in a teaching hospital.twenty-seven patients (21M e 6F), aging 14 - 58 years, with severe acute brain trauma, presenting with three to eight points on the Glasgow Coma Scale, were prospectively evaluated according to a cumulative protocol for the management of acute intracranial hypertension, where intracranial pressure (ICP) and cerebral extraction of oxygen (CEO2) were routinely measured. Hemometabolic interrelationships involving mean arterial pressure (MAP), ICP, arterial carbon dioxide tension (PaCO2), CEO2, cerebral perfusion pressure (CPP) and systemic extraction of oxygen (SEO2) were analyzed.routine therapeutic procedures.no correlation was found between CEO2 and CPP (r = -0.07; p = 0.41). There was a significant negative correlation between PaCO2 and CEO2 (r = -0.24; p = 0.005) and a positive correlation between SEO2 and CEO2 (r = 0.24; p = 0.01). The mortality rate in this group of patients was 25.9% (7/27).1) CPP and CEO2 are unrelated; 2) CEO2 and PaCO2 are closely related; 3) during optimized hyperventilation, CEO2 and SEO2 are coupled.

Since Aubaniac (1) described the puncture of the subclavian vein in 1952, and specially after the standardization of parenteral nutrition by Dudrick et al. (11) in 1968, much has been published about complications caused by percutaneous central venous catheterization. Among the various complications provoked by this procedure, a very important one is "primary sepsis" or "catheter-related sepsis", both because of its frequency and because of the morbidity and mortality it causes (18,19). It is, however, difficult to diagnose this complication. The main difficulty lies in differentiating catheters that are really causing sepsis from those that, though showing "positive culture" do not cause bacteremia and are not responsible for the occasional signs of infection that a patient may show (6,7). This difficulty in diagnosing has led to the recommendation that all catheters suspected of causing sepsis be systematically removed. This procedure has the effect of exposing patients in serious condition and with limited venous access to the risks of new punctures. Usually these risks are unnecessary, since 75 to 90% of the catheters removed for this reason are not the real source of infection (3, 17, 19, 21, 22). In 1977, Maki et al. (18) proposed a semiquantitative catheter tip culture that showed considerable correlation with positive hemoculture for the same microorganisms; that is, capable of identifying which "positive catheters" were really causing sepsis. Subsequent research confirmed these results, showing that the semiquantitative catheter tip culture had specificity and sensibility over 80% (10, 15).(ABSTRACT TRUNCATED AT 250 WORDS)