Introdução: O prognóstico da parada cardiorrespiratória (PCR) em ritmo não chocável (assistolia/atividade elétrica sem pulso) é ruim e não melhorou significativamente nas últimas décadas. Embora a epinefrina seja o vasopressor recomendado, há evidências de que ela eleva o consumo de oxigênio, reduz a pressão de perfusão subendocárdica, causa grave disfunção miocárdica e piora a microcirculação cerebral durante a ressuscitação cardiopulmonar. Vasopressina foi muito estudada nos últimos anos e não se mostrou superior à epinefrina. Naloxona e terlipressina têm sido cogitadas como potenciais vasopressores no tratamento da PCR, entretanto há poucos estudos publicados e os resultados são controversos e inconclusivos. Objetivos: Avaliar os efeitos hemodinâmicos e metabólicos da terlipressina ou naloxona na PCR induzida por hipóxia e compará-las com o tratamento-padrão (epinefrina ou vasopressina). Métodos: Estudo experimental, randomizado, cego e controlado. Ratos Wistar adultos, machos, foram anestesiados, submetidos a traqueostomia e ventilados mecanicamente. A PCR foi induzida por obstrução da traqueia e mantida por 3,5 minutos. Em seguida, os animais foram ressuscitados de forma padronizada e randomizados em um dos grupos: placebo (n = 7), vasopressina (n = 7), epinefrina (n = 7), naloxona (n = 7) ou terlipressina (n = 21). Variáveis hemodinâmicas foram monitorizadas durante todo o experimento (via cateter intra-arterial e intraventricular) e mensuradas na base, no 10o (T10), 20o (T20), 30o (T30), 45o (T45) e 60o (T60) minutos pós-PCR. Amostras de sangue arterial foram coletadas para gasometria, hemoglobina, bioquímica e lactato em quatro momentos [base, 11o (T11), 31o (T31), e 59o (T59) minutos pós-PCR]. Resultados: Os grupos foram homogêneos e não houve diferença significativa entre eles nas variáveis de base. O retorno da circulação espontânea ocorreu em 57% dos animais no grupo placebo (4 de 7) e 100% nos demais grupos (p = 0,002). A ! sobrevida em 1 hora foi de 57% no grupo placebo, 71,4% no grupo epinefrina, 90,5% no grupo terlipressina e de 100% nos demais grupos. Comparado com o grupo epinefrina, o grupo terlipressina teve maiores valores de PAM no T10 (164 vs 111 mmHg; p = 0,02), T20 (157 vs 97 mmHg; p < 0,0001), T30 (140 vs 67 mmHg; p < 0,0001), T45 (117 vs 67 mmHg; p = 0,002) e T60 (98 vs 62 mmHg; p = 0,026). O lactato arterial no grupo naloxona foi significativamente menor quando comparado ao grupo epinefrina, no T11 (5,15 vs 8,82 mmol/L), T31 (2,57 vs 5,24 mmol/L) e T59 (2,1 vs 4,1 mmol/L)[p = 0,002]. Ao longo da 1a hora pós-PCR, o grupo naloxona apresentou o melhor perfil do excesso de bases (-7,78 mmol/L) quando comparado ao grupo epinefrina (-12,78 mmol/L; p = 0,014) e ao grupo terlipressina (-11,31 mmol/L; p = 0,024). Conclusões: Neste modelo de PCR induzida por hipóxia em ratos, terlipressina e naloxona foram eficazes como vasopressores na RCP e apresentaram melhor perfil metabólico que a epinefrina. A terlipressina resultou em uma maior estabilidade hemodinâmica na 1a hora pós-PCR comparada com a epinefrina ou a vasopressina. Os efeitos metabólicos favoráveis da naloxona não são explicados pelos valores da PAM / Introduction: The prognosis of cardiac arrest (CA) with nonshockable rhythm (asystole/pulseless electrical activity) is poor and not improved significantly in recent decades. Epinephrine is the most commonly used vasopressor, although there is evidence that its use correlates with myocardial dysfunction and worsens the cerebral microcirculation. Vasopressin has been widely studied in recent years and was not superior to epinephrine. Naloxone and terlipressin have been considered as potential vasopressors in the treatment of CA, however, there are few published studies and the results are controversial and inconclusive. Objectives: To evaluate the hemodynamic and metabolic effects of terlipressin or naloxone in CA induced by hypoxia and compare with standard treatment with epinephrine or vasopressin. Methods: Experimental, randomized, blinded and controlled trial. Adult male Wistar rats were anesthetized, the proximal trachea was surgically exposed, and a 14-gauge cannula was inserted 10 mm into the trachea to the larynx. They were mechanically ventilated and monitored. The CA was induced by tracheal obstruction and maintained for 3.5 minutes. Subsequently, the animals were resuscitated using standard maneuvers and randomized to one of groups: placebo (n=7), vasopressin (n=7), epinephrine (n=7), naloxone (n=7) or terlipressin (n=21). Hemodynamic variables were monitored throughout the study (intra-arterial and intra-ventricular catheter) and measured at baseline, in the 10th (T10), 20th (T20), 30th (T30), 45th (T45) and 60th (T60) minute post-cardiac arrest. Arterial blood samples were collected for hemoglobin, biochemistry, blood gases and lactate at four moments: baseline, 11th (T11), 31st (T31) and 59th (T59) minute post-cardiac arrest. Results: The groups were homogenous and there were no significant differences among them regarding the baseline variables. The return of spontaneous circulation (ROSC) occurred in 57% of the animals (4 of 7) in the placebo group and in 100% in the ! other groups (P=0.002). One-hour survival was 57% in the placebo group, 71.4% in the epinephrine group, 90.5% in the terlipressin and 100% in the naloxone group. Compared with the epinephrine group, the terlipressin groups had a significantly higher MAP at the T10 (164 x 111 mmHg; P=0.02), T20 (157 x 97 mmHg; P<0.0001), T30 (140 x 67 mmHg; P=0.0001), T45 (117 x 67 mmHg; P=0.002) and T60 (98 x 62 mmHg; P= 0.026). The blood lactate in naloxone group was significantly lower when compared to epinephrine group in the T11 (5.15 x 8.82 mmol/L), T31 (2.57 x 5.24 mmol/L) and T59 (2.1 x 4.1)[P=0.002]. Along the first hour after cardiac arrest, the naloxone group showed the best profile of base excess (- 7.78 mmol/L) when compared to epinephrine (-12.78 mmol/L, P= 0.014) and terlipressin group (-11.31 mmol/L, P=0.024). Conclusions: In this model of CA induced by hypoxia in rats, terlipressin and naloxone were effective as vasopressors in resuscitation and had better metabolic profile compared to epinephrine. Terlipressin resulted in higher hemodynamic stability in the first hour after CA and significantly better than epinephrine or vasopressin. The favorable metabolic effects of naloxone are not explained by the values of MAP

Introdução: Apesar do desenvolvimento tecnológico, permanece baixa a sobrevida hospitalar das vítimas de parada cardiorrespiratória extra-hospitalar. Há importante dúvida na literatura quanto à retenção de habilidades de ressuscitação cardiopulmonar (RCP) e a periodicidade adequada de treinamento para manutenção dessas habilidades. O presente estudo investigou a retenção, em alunos a partir de treinamento no primeiro semestre de ingresso no curso médico, das habilidades práticas de RCP até 42 meses após o referido treinamento. Métodos: Estudo de corte transversal, realizado com 298 alunos de graduação de uma faculdade de Medicina, treinados com base nas diretrizes de ressuscitação de 2010 da American Heart Association. Foram avaliados 205 alunos sem retreinamento das habilidades, divididos em quatro grupos conforme o tempo decorrido desde o treinamento de ingresso: 73 alunos após 1 mês, 55 após 18 meses, 41 após 30 meses e 36 após 42 meses. A análise da retenção das habilidades foi comparada com 93 alunos que referiram ter realizado retreinamento em RCP. Dezenove habilidades de RCP e nove potenciais erros de técnica na execução das ventilações pulmonares e compressões torácicas foram avaliados por meio de simulação realística e revisados com utilização de filmagem e avaliadores independentes. Resultados: A média de retenção das dezenove habilidades nos alunos sem retreinamento foi: 90% após 1 mês, 74% após 18 meses, 62% após 30 meses e 61% após 42 meses (p < 0,001). Nos alunos que referiram retreinamento, a retenção foi de 74% após 18 meses, 70% após 30 meses e 66% após 42 meses do treinamento inicial. Realizada curva de predição da retenção de habilidades, com estimativa de 80% das habilidades mantidas após 10 meses, 70% após 21 meses e 60% após 42 meses. A profundidade das compressões torácicas foi a habilidade com maior retenção ao longo do tempo (87,8%), sem diferença estatística entre os quatro grupos. Houve aumento da prevalência de compressões realizadas com menos de 5 cm de profundidade quando realizadas em frequência maior que 120 por minuto. A média da frequência de compressões torácicas obtidas nos grupos após 1, 18, 30 e 42 meses foi, respectivamente, 114, 114, 104 e 108 compressões por minuto; 104 (50,7%) alunos mantiveram frequência média entre 100-120 por minuto. As ventilações pulmonares apresentaram diminuição progressiva de retenção, de 93% após 1 mês até 19% após 42 meses (p < 0,001). Todos os alunos efetivaram o choque com o desfibrilador externo automático, porém com o grupo após 1 mês do treinamento com menor tempo para efetivação do choque e maior prevalência de posicionamento adequado das pás do desfibrilador. Conclusões: O presente estudo demonstrou diferentes níveis de retenção para as habilidades de RCP e diferentes níveis de decréscimo de tais habilidades ao longo de 42 meses. A profundidade das compressões torácicas e o uso do desfibrilador externo automático foram as habilidades com maior retenção ao longo do tempo. Treinamentos adicionais ao longo do curso de Medicina atenuaram a perda de habilidades, mas sem retorno ao desempenho observado após 1 mês do treinamento. Sugerimos que o intervalo mínimo de retreinamento para manutenção de pelo menos 70% das habilidades deva ser de 18 a 24 meses / Introduction: Despite technological development, the survival of victims of out-ofhospital cardiac arrest remains low. There are important questions in the literature regarding the retention of cardiopulmonary resuscitation (CPR) skills and the ideal frequency of retraining required to enhance retention of skills. This study investigated the retention of practical CPR skills by medical students over 42 months after training in the first semester of admission to the medical course. Methods: A cross-sectional study was conducted with 298 undergraduate medical students who were trained based on the 2010 American Heart Association resuscitation guidelines. A total of 205 students divided into four groups according to the time elapsed since the entrance training were evaluated without retraining (73 students after 1 month, 55 students after 18 months, 41 students after 30 months and 36 students after 42 months). The analysis of the retention of skills was compared to 93 students who reported having performed retraining in CPR. Nineteen CPR skills and nine potential technical errors in ventilations and chest compressions were evaluated by realistic simulation and reviewed using filming by independent examiners. Results: The mean retention of the nineteen skills in not retrained students was: 90% after 1 month, 74% after 18 months, 62% after 30 months and 61% after 42 months (p < 0.001). In retraining students, retention was 74% after 18 months, 70% after 30 months, and 66% after 42 months of initial training, with statistical difference between the students with and without retraining in the 30-month group (p=0.005). The estimation of mean skill retention was 80% after 10 months, 70% after 21 months and 60% after 42 months. The depth of chest compressions was the skill with greater retention over time (87.8%), with no statistical difference among groups. There was an increase in the prevalence of compressions performed with less than 5 cm depth when performed at a frequency greater than 120 per minute. The mean chest compressions rate obtained in the groups after 1, 18, 30 and 42 months were 114, 114, 104 and 108 per minute, respectively, and 104 (50.7%) students maintained a mean frequency of 100-120 per minute. Pulmonary ventilation showed a progressive decrease in retention from 93% after 1 month to 19% after 42 months (p < 0.001). All students delivered the shock with the automated external defibrillator; however, for the group one month post-training, the time for the application of the shock was lower, and the prevalence of adequate positioning of the defibrillator pads was greater. Conclusion: This study showed different retention levels for CPR skills and different decrease levels of these skills over 42 months. Depth of chest compressions and use of automated external defibrillator were the skills with the highest retention over time. Additional training throughout the medical course attenuated the loss of skills, but no return to the initial performance achieved after 1 month. We suggest that the minimum retraining interval for maintenance of at least 70% of skills should be 18 to 24 months

Pacientes submetidos à revascularização do miocárdio (RM), frequentemente utilizam beta-bloqueadores no pré-operatório para o controle da angina pectoris, e continuam o tratamento após a cirurgia, para a redução de mortalidade e complicações cardiovasculares perioperatórias. Entretanto, a circulação extracorpórea (CEC), empregada na maioria das cirurgias cardíacas, pode alterar as concentrações plasmáticas e a disposição cinética de muitos fármacos, e consequentemente seus efeitos terapêuticos. O atenolol é um beta-bloqueador altamente hidrossolúvel, de absorção incompleta e eliminação renal-dependente. O objetivo deste estudo foi o de investigar a influência da CEC sobre as concentrações plasmáticas do atenolol no intra-operatório de cirurgia cardíaca, além de comparar a sua farmacocinética no pré e pós-operatório de RM com CEC, em pacientes com insuficiência coronariana. Investigou-se ainda, a variabilidade das concentrações plasmáticas do atenolol no período que antecede a cirurgia cardíaca. Na primeira etapa, avaliaram-se 19 pacientes coronarianos, em terapia crônica com atenolol PO, submetidos à cirurgia cardíaca com ou sem CEC. Na segunda parte, investigaram-se os períodos pré e pós-cirúrgico de 7 pacientes submetidos à RM com CEC e tratados com atenolol PO em regime de doses múltiplas. Todos os pacientes investigados apresentavam função renal dentro da normalidade ou leve disfunção renal, decorrente da idade e da insuficiência coronariana. O monitoramento do atenolol plasmático no intra-operatório de RM e o estudo farmacocinético realizado antes e após a revascularização, exigiram coletas de amostras sangüíneas seriadas. A quantificação do atenolol em plasma foi realizada através da cromatografia líquida de alta eficiência com detector de fluorescência e consistiu num procedimento analítico rápido, simples e de baixo custo. Apenas 200 L de plasma foram utilizados em cada análise cromatográfica. O estudo de validação demonstrou que o método desenvolvido apresenta alta linearidade, sensibilidade e seletividade adequadas, alta recuperação, boa precisão e exatidão, além de estabilidade e robustez. Conclui-se que a circulação extracorpórea altera as concentrações do atenolol no intra-operatório de RM, visto que o decaimento das concentrações plasmáticas mostrou-se mais pronunciado na ausência da CEC. Entretanto, apesar das maiores concentrações obtidas ao final da cirurgia com CEC, o atenolol mostra-se seguro, em virtude do baixo acúmulo do fármaco administrado em regime de doses múltiplas. Além disso, a disposição cinética do atenolol permaneceu inalterada, quando os períodos pré e pós-operatórios foram comparados; entretanto, registrou-se uma tendência à normalização do volume de distribuição e da depuração plasmática do atenolol após a revascularização. Adicionalmente, a ausência de correlação entre meia-vida biológica e volume aparente de distribuição sugere que, tanto no pré quanto no pós-operatório, as concentrações do atenolol dependem apenas da sua depuração plasmática. Finalmente, verificou-se que o atenolol apresenta baixa variabilidade inter-pacientes nos regimes posológicos empregados no tratamento da insuficiência coronariana. / Patients submitted to coronary artery bypass grafting (CABG) surgery frequently are using beta-blockers agents for the control of angina pectoris, and continue the treatment after the surgery to reduce the mortality and cardiovascular events. However, the technique of cardiopulmonary bypass (CPB), used in most cardiac surgeries with cardioplegia, causes important changes in the plasma concentrations and pharmacokinetics of many drugs and may also alter their therapeutic effects. Atenolol is a hydrophilic beta-blocker characterized by incomplete absorption, a relatively small volume of distribution and a renal function-dependent elimination. The objective of this study was to investigate the effects of CPB on the plasma concentrations of atenolol during the intra-operative period of cardiac surgery, as well as, to compare the pharmacokinetics of atenolol in the pre and post-operative periods of revascularization with CPB, in patients with coronary insufficiency. In addition, it was investigated the variability of plasma atenolol concentrations before the cardiac surgery. In the first part of the study, it was investigated 19 coronary patients, under chronic therapy with atenolol and submitted to cardiac surgery performed with and without CPB. At the second part, it was evaluated the pre and post-operative periods from 7 patients submitted to the CABG surgery with CPB, who were chronically treated with atenolol in a multiple regimen. All enrolled patients presented normal or slightly reduced renal function as a result of age and underlying disease. A serial blood samples collection was required for monitoring of plasma atenolol concentrations at the intra-operative period and also for pharmacokinetic study at the pre and post-CABG. The quantification of plasma atenolol was performed using high-performance liquid chromatography with fluorescence detection and consisted of a relatively rapid, simple and low-cost analytical procedure. Only 200 µL of plasma was used for each chromatographic analysis. Validation of this analytical method showed high linearity, adequate sensitivity and selectivity, high recovery, good accuracy and precision, in addition to stability and a guarantee of robustness. It was concluded that the CPB changes plasma atenolol concentrations in the intra-operative period, since a marked decrease in plasma atenolol concentrations was observed in patients undergoing cardiac surgery without CPB. Thus, despite the lower decline in plasma levels observed in patients submitted to CPB, atenolol can be used safely, due to the low accumulation of the drug administrated at multiple dose regimens. In addition, pharmacokinetics of atenolol remained unaltered when pre and post-operative periods were compared; although it was observed a tendency of normalization of volume of distribution and plasma clearance of atenolol after the revascularization. Moreover, the lack of correlation between biological half-life and apparent volume of distribution suggests that, in both periods, plasma atenolol concentration only depends on its plasma clearance. Finally, it was verified a small inter-patient variability of atenolol in the dose regimens used for the control of coronary insufficiency.

Realizamos este estudo com o objetivo de analisar as principais variáveis clínicas dos pacientes que sofreram parada cardiorrespiratória e detectar fatores prognósticos de sobrevivência a curto e longo prazos, tentando oferecer subsídios aos profissionais de saúde que estão envolvidos com reanimação. Analisamos prospectivamente 452 pacientes que receberam reanimação em hospitais gerais de Salvador. Utilizou-se análise bivariada e estratificada nas associações entre as variáveis e a curva de sobrevida para análise de nove anos de evolução. Observamos 24% de sobrevida imediata e 5% de sobrevida à alta hospitalar. Os fatores prognósticos de sobrevida imediata foram: ter doença de base, a enfermidade cardiovascular, diagnosticar o ritmo cardíaco , ritmo de fibrilação ou taquicardia ventricular, tempo estimado pré-reanimação menor ou igual a cinco minutos; tempo de reanimação menor ou igual a 15 minutos. As variáveis prognósticas sobrevida a longo prazo foram: não usar adrenalina; ser reanimado em hospital privado;tempo de reanimação menor ou igual a 15 minutos / The objectives of this study are to analyze the main clinical and demographic characteristics of patients who suffer cardiac arrest and identify variables involved in survival outcomes. The study enrolled 452 patients, which received cardiopulmonary resuscitation in general hospitals. We prospectively analyzed the main variables associated with ROSC and survival to hospital discharge utilizing bivariate and stratified. The Kaplan-Meier technique was used to analyze the survival curves after nine years. Of the 452 resuscitation attempts, 107 (24%) patients had ROSC and only 22 (5%) were discharge from hospital. The variables with greatest prognostic value for immediate survival were: having a co-morbid condition, cardiovascular disease as the etiology, determination of cardiac rhythm, ventricular arrhythmia as rhythm of arrest, estimated pre-resuscitation time less than or equal to 5 minutes and the resuscitation effort duration less than or equal to 15 minutes. The variables associated with better long term survival were: not using adrenaline, being resuscitated in a private hospital and resuscitation efforts lasting less than or equal to 15 minutes

Introduction: The most appropriate airway management technique for use by paramedics in out-of-hospital cardiac arrest is yet to be determined and evidence relating to the influence of airway management strategy on outcome remains equivocal. In cases where return of spontaneous circulation (ROSC) occurs following out-of-hospital cardiac arrest, patients may undergo direct transfer to a specialist heart attack centre (HAC) where the post resuscitation 12 lead ECG demonstrates evidence of ST elevation myocardial infarction. To date, no studies have investigated the role of airway management strategy on outcomes in this sub-set of patients. The AMICABLE (Airway Management In Cardiac Arrest, Basic, Laryngeal mask airway, Endotracheal intubation) study therefore sought to investigate the influence of prehospital airway management strategy on outcomes in patients transferred by the ambulance service directly to a HAC post ROSC. Methods: Adults with ROSC post out-of-hospital cardiac arrest who met local criteria for transfer to a HAC were identified prospectively. Ambulance records were reviewed to determine prehospital airway management approach and collect physiological and demographic data. HAC notes were obtained to determine in-hospital course and quantify neurological outcome via the Cerebral Performance Category (CPC) scale. Neurologically intact survivors were contacted post discharge to assess quality of life via the SF-36 health survey. Statistical analyses were performed via Chi-square, Mann Whitney U test, odds ratios, and binomial logistic regression. Results: A total of 220 patients were recruited between August 2013 and August 2014, with complete outcome data available for 209. The age of patients ranged from 22-96 years and 71.3% were male (n=149). Airway management was undertaken using a supraglottic airway (SGA) in 72.7% of cases (n=152) with the remainder undergoing endotracheal intubation (ETI). There was no significant difference in the proportion of patients with good neurological outcome (CPC 1&2) between the SGA and ETI groups (p=.286). Similarly, binomial logistic regression incorporating factors known to influence outcome demonstrated no significant difference between the SGA and ETI groups (Adjusted OR 0.725, 95% CI 0.337-1.561). Clinical and demographic variables associated with good neurological outcome included the presence of a shockable rhythm (p < .001), exposure to angiography (p < .001), younger age (p < .001) and shorter time to ROSC (p < .001). Due to an inadequate response rate (25.4%, n=15) analysis of SF36 data was limited to descriptive statistics. Limitations: The study only included patients who achieved ROSC and met the criteria for direct transfer to a HAC. Results are therefore not generalisable to more heterogenous resuscitation populations. Accuracy of clinical decision making and ECG interpretation were not assessed and therefore some patients included in the study may have been inappropriately transferred to a HAC. The low SF-36 survey response rate limited the level of neurological outcome analysis that could be undertaken. Conclusion: In this study, there was no significant difference in the proportion of good neurological outcomes in patients managed with SGA versus ETI during cardiac arrest. Further research incorporating randomised controlled trials is required to provide more definitive evidence in relation to the optimal airway management strategy in out-of-hospital cardiac arrest.

L’insuffisance cardiaque aigue est une émergence médicale qui nécessite une prise en charge multidisciplinaire. L’Extracorporeal Life Support (ECLS) peut être envisagé comme option thérapeutique pour les formes d’insuffisance cardiaque aigue réfractaire au traitement conventionnel. L’objectif de ce projet de recherche clinique est de fournir une vue d’ensemble de l’ECLS dans la prise en charge du choc cardiogénique et de l’arrêt cardiaque réfractaire. L’intoxication médicamenteuse et la myocardite sont les meilleures indications à l’implantation de l’ECLS en considération de leur potentiel de récupération myocardique très élevé. La défaillance primaire du greffon après transplantation cardiaque et l’infarctus du myocarde présentent des résultats plus mitigés avec l’ECLS en raison d’une physiopathologie plus complexe. Le choc cardiogénique postcardiotomie après une intervention de chirurgie cardiaque montre des résultats décevants en raison du profile préopératoire des patients. L’arrêt cardiaque aussi exige une prise en charge immédiate et l’ECLS peut être considéré comme une solution thérapeutique de sauvetage. Une meilleure sélection des patients s’impose afin d’améliorer les résultats de l’ECLS pour l’arrêt cardiaque réfractaire intrahospitalier. Les résultats de l’ECLS pour l’arrêt cardiaque réfractaire extrahospitalier sont dictés principalement par le temps de réanimation cardio-pulmonaire et le rythme cardiaque. Les rythmes non choquables pourraient être considérés comme une contre-indication formelle à l’utilisation de l’ECLS autorisant une concentration de nos efforts sur les rythmes choquables où les chances de survie sont plus importantes / Acute heart failure is a clinical situation requiring a prompt multidisciplinary approach. Extracorporeal Life Support (ECLS) could represent a therapeutic option for acute heart failure refractory to standard maximal treatment. The aim of this report is to offer an overview of ECLS in the management of refractory cardiogenic shock and cardiac arrest. Drug intoxication and myocarditis are the best indications of ECLS in consideration of their high potential of myocardial recovery. Primary graft dysfunction after heart transplantation and acute myocardial infarction show reduced survival rates owing to their more complex pathophysiology. Postcardiotomy cardiogenic shock after cardiac surgery operations displays poor outcomes due to the preoperative profile of the patients. ECLS could be also considered as a rescue solution for refractory cardiac arrest. A better selection of in-hospital cardiac arrest patients is mandatory to improve ECLS outcomes. In-hospital cardiac arrest patients with a reversible cause like drug intoxication and acute coronary syndrome should benefit from ECLS whereas end-stage cardiomyopathy and postcardiotomy patients with an unclear cause of cardiac arrest should be contraindicated to avoid futile support. ECLS for refractory out-ofhospital cardiac arrest should be limited in consideration of its poor, especially neurological, outcome and the results are mainly limited by the low-flow duration and cardiac rhythm. Nonshockable rhythms could be considered as a formal contraindication to ECLS for refractory out-of-hospital cardiac arrest allowing a concentration of our efforts on the shockable rhythms, where the chances of success are substantial

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Made available in DSpace on 2016-01-26T12:51:50Z (GMT). No. of bitstreams: 1 liliangoraieb_dissert.pdf: 2524026 bytes, checksum: 35df67e734bc16baa9fa59b0adee085f (MD5) Previous issue date: 2005-12-12 / Objective: To evaluate the behavior of the pulmonary compliance and resistance of the airway passage in patients with high blood flow congenital heart disease undergoing surgical treatment with cardiopulmonary bypass. Method: The static pulmonary compliance and the airway resistance were evaluated in 35 patients during the intraoperative period, in four distinct instants: the first, before the thorax opening, with the infants being already anesthetized, under mechanical ventilation; the second, after thorax and pericardium opening, with the retractors in position; the third, five minutes after the end of cardiopulmonary bypass; the forth, after thorax closing. Pulmonary measurements were performed non-invasively by means of the airway occlusion at the end of inspiration, and the use of proper mathematical formula. In different periods, the observed and related variables with the pulmonary changes were: preoperative, the age, weight and systemic and pulmonary blood flow; intraoperative, the perfusion and the anoxia duration and the minimum body temperature; and, postoperative, duration of mechanical ventilatory support and the length of stay in the ICU. Results: At the end of the surgery, the pulmonary compliance showed a significant and immediate increase (P<0.001) in all the patients. Patients over 30-months as well as the ones with weight over 10kg showed greater increase; P=0.0004, P=0.0006, respectively. Patients with 50-minute duration of cardiopulmonary bypass delayed more to present increase of pulmonary compliance (P=0.04). The resistance of the airway passage did not present significant alteration at the end of surgical correction (P=0.393). Conclusion: All the patients presented pulmonary compliance improvement at the end of the surgery. It was influenced significantly by the age, weight and duration of cardiopulmonary bypass; however, the resistance of the airway passage has not changed. / Avaliar o comportamento da complacência pulmonar e resistência da via aérea nos pacientes portadores de cardiopatias congênitas com hiperfluxo pulmonar submetidos a tratamento cirúrgico com auxílio de circulação extracorpórea. Método: Trinta e cinco pacientes foram avaliados com medidas de complacência estática e resistência da via aérea em quatro instantes distintos durante a cirurgia: O primeiro antes da abertura do tórax, com a criança já anestesiada e sob ventilação mecânica. O segundo, após a abertura do tórax e pericárdio, com os afastadores posicionados. O terceiro, cinco minutos após a saída de circulação extracorpórea e o quarto, após o fechamento do tórax. As medidas pulmonares foram feitas de forma não invasiva com o método de oclusão da via aérea ao final da inspiração e uso de fórmulas matemáticas específicas. As variáveis observadas e relacionadas às alterações pulmonares foram: No período pré-operatório, idade, peso e a relação entre fluxo sanguíneo sistêmico e pulmonar, no intra-operatório, tempos de perfusão, de anóxia e temperatura mínima, no pós-operatório, tempo de ventilação mecânica e tempo de permanência na unidade de terapia intensiva. Resultados: A Complacência pulmonar ao final da cirurgia mostrou aumento significativo imediato (P<0,001) em todos os pacientes. Pacientes maiores de 30 meses tiveram maior aumento (P=0,0004). Os com peso superior a 10kg também apresentaram maior aumento (P=0,0006). Pacientes com tempo de circulação extracorpórea maior que 50 minutos demoraram mais para apresentar aumento da complacência pulmonar (P=0,04). A resistência da via aérea não apresentou alteração significativa ao final da correção cirúrgica (P=0,393). Conclusão: A complacência pulmonar apresentou melhora ao final da cirurgia em todos os pacientes, sendo influenciada de forma significativa pela idade, peso e tempo de circulação extracorpórea. A resistência da via aérea, entretanto, não se alterou.

Introdução: O prognóstico da parada cardiorrespiratória (PCR) em ritmo não chocável (assistolia/atividade elétrica sem pulso) é ruim e não melhorou significativamente nas últimas décadas. Embora a epinefrina seja o vasopressor recomendado, há evidências de que ela eleva o consumo de oxigênio, reduz a pressão de perfusão subendocárdica, causa grave disfunção miocárdica e piora a microcirculação cerebral durante a ressuscitação cardiopulmonar. Vasopressina foi muito estudada nos últimos anos e não se mostrou superior à epinefrina. Naloxona e terlipressina têm sido cogitadas como potenciais vasopressores no tratamento da PCR, entretanto há poucos estudos publicados e os resultados são controversos e inconclusivos. Objetivos: Avaliar os efeitos hemodinâmicos e metabólicos da terlipressina ou naloxona na PCR induzida por hipóxia e compará-las com o tratamento-padrão (epinefrina ou vasopressina). Métodos: Estudo experimental, randomizado, cego e controlado. Ratos Wistar adultos, machos, foram anestesiados, submetidos a traqueostomia e ventilados mecanicamente. A PCR foi induzida por obstrução da traqueia e mantida por 3,5 minutos. Em seguida, os animais foram ressuscitados de forma padronizada e randomizados em um dos grupos: placebo (n = 7), vasopressina (n = 7), epinefrina (n = 7), naloxona (n = 7) ou terlipressina (n = 21). Variáveis hemodinâmicas foram monitorizadas durante todo o experimento (via cateter intra-arterial e intraventricular) e mensuradas na base, no 10o (T10), 20o (T20), 30o (T30), 45o (T45) e 60o (T60) minutos pós-PCR. Amostras de sangue arterial foram coletadas para gasometria, hemoglobina, bioquímica e lactato em quatro momentos [base, 11o (T11), 31o (T31), e 59o (T59) minutos pós-PCR]. Resultados: Os grupos foram homogêneos e não houve diferença significativa entre eles nas variáveis de base. O retorno da circulação espontânea ocorreu em 57% dos animais no grupo placebo (4 de 7) e 100% nos demais grupos (p = 0,002). A ! sobrevida em 1 hora foi de 57% no grupo placebo, 71,4% no grupo epinefrina, 90,5% no grupo terlipressina e de 100% nos demais grupos. Comparado com o grupo epinefrina, o grupo terlipressina teve maiores valores de PAM no T10 (164 vs 111 mmHg; p = 0,02), T20 (157 vs 97 mmHg; p < 0,0001), T30 (140 vs 67 mmHg; p < 0,0001), T45 (117 vs 67 mmHg; p = 0,002) e T60 (98 vs 62 mmHg; p = 0,026). O lactato arterial no grupo naloxona foi significativamente menor quando comparado ao grupo epinefrina, no T11 (5,15 vs 8,82 mmol/L), T31 (2,57 vs 5,24 mmol/L) e T59 (2,1 vs 4,1 mmol/L)[p = 0,002]. Ao longo da 1a hora pós-PCR, o grupo naloxona apresentou o melhor perfil do excesso de bases (-7,78 mmol/L) quando comparado ao grupo epinefrina (-12,78 mmol/L; p = 0,014) e ao grupo terlipressina (-11,31 mmol/L; p = 0,024). Conclusões: Neste modelo de PCR induzida por hipóxia em ratos, terlipressina e naloxona foram eficazes como vasopressores na RCP e apresentaram melhor perfil metabólico que a epinefrina. A terlipressina resultou em uma maior estabilidade hemodinâmica na 1a hora pós-PCR comparada com a epinefrina ou a vasopressina. Os efeitos metabólicos favoráveis da naloxona não são explicados pelos valores da PAM / Introduction: The prognosis of cardiac arrest (CA) with nonshockable rhythm (asystole/pulseless electrical activity) is poor and not improved significantly in recent decades. Epinephrine is the most commonly used vasopressor, although there is evidence that its use correlates with myocardial dysfunction and worsens the cerebral microcirculation. Vasopressin has been widely studied in recent years and was not superior to epinephrine. Naloxone and terlipressin have been considered as potential vasopressors in the treatment of CA, however, there are few published studies and the results are controversial and inconclusive. Objectives: To evaluate the hemodynamic and metabolic effects of terlipressin or naloxone in CA induced by hypoxia and compare with standard treatment with epinephrine or vasopressin. Methods: Experimental, randomized, blinded and controlled trial. Adult male Wistar rats were anesthetized, the proximal trachea was surgically exposed, and a 14-gauge cannula was inserted 10 mm into the trachea to the larynx. They were mechanically ventilated and monitored. The CA was induced by tracheal obstruction and maintained for 3.5 minutes. Subsequently, the animals were resuscitated using standard maneuvers and randomized to one of groups: placebo (n=7), vasopressin (n=7), epinephrine (n=7), naloxone (n=7) or terlipressin (n=21). Hemodynamic variables were monitored throughout the study (intra-arterial and intra-ventricular catheter) and measured at baseline, in the 10th (T10), 20th (T20), 30th (T30), 45th (T45) and 60th (T60) minute post-cardiac arrest. Arterial blood samples were collected for hemoglobin, biochemistry, blood gases and lactate at four moments: baseline, 11th (T11), 31st (T31) and 59th (T59) minute post-cardiac arrest. Results: The groups were homogenous and there were no significant differences among them regarding the baseline variables. The return of spontaneous circulation (ROSC) occurred in 57% of the animals (4 of 7) in the placebo group and in 100% in the ! other groups (P=0.002). One-hour survival was 57% in the placebo group, 71.4% in the epinephrine group, 90.5% in the terlipressin and 100% in the naloxone group. Compared with the epinephrine group, the terlipressin groups had a significantly higher MAP at the T10 (164 x 111 mmHg; P=0.02), T20 (157 x 97 mmHg; P<0.0001), T30 (140 x 67 mmHg; P=0.0001), T45 (117 x 67 mmHg; P=0.002) and T60 (98 x 62 mmHg; P= 0.026). The blood lactate in naloxone group was significantly lower when compared to epinephrine group in the T11 (5.15 x 8.82 mmol/L), T31 (2.57 x 5.24 mmol/L) and T59 (2.1 x 4.1)[P=0.002]. Along the first hour after cardiac arrest, the naloxone group showed the best profile of base excess (- 7.78 mmol/L) when compared to epinephrine (-12.78 mmol/L, P= 0.014) and terlipressin group (-11.31 mmol/L, P=0.024). Conclusions: In this model of CA induced by hypoxia in rats, terlipressin and naloxone were effective as vasopressors in resuscitation and had better metabolic profile compared to epinephrine. Terlipressin resulted in higher hemodynamic stability in the first hour after CA and significantly better than epinephrine or vasopressin. The favorable metabolic effects of naloxone are not explained by the values of MAP

La circulation extracorporelle (CEC) déclenche une réaction inflammatoire systémique, un dommage d’ischémie-reperfusion (I-R) et une dysfonction de l’endothélium dans la circulation pulmonaire. L’hypertension pulmonaire (HTP) est la conséquence de cette cascade de réactions. Cette HTP augmente le travail du ventricule droit et peut causer sa dysfonction, un sevrage difficile de la CEC et une augmentation des besoins de vasopresseurs après la chirurgie cardiaque. L’administration de milrinone et d’époprosténol inhalés a démontré une réduction de la dysfonction endothéliale dans l’artère pulmonaire. Le but de ce travail est d’évaluer différents types de nébulisateur pour l’administration de la milrinone et d’évaluer l’effet du traitement préventif de la combinaison de milrinone et époprosténol inhalés sur les résultats postopératoires en chirurgie cardiaque. Deux études ont été conduites. Dans la première, trois groupes de porcelets ont été comparés : (1) groupe milrinone avec nébulisateur ultrasonique ; CEC et reperfusion précédées par 2,5 mg de milrinone inhalée, (2) goupe milrinone avec nébulisateur à simple jet ; CEC et reperfusion précédées par 2,5 mg de milrinone inhalée et (3) groupe contrôle ; CEC et reperfusion sans traitement. Durant la procédure, les paramètres hémodynamiques, biochimiques et hématologiques ont été mesurés. Après sacrifice, la relaxation endothélium dépendante de l’artère pulmonaire à l’acétylcholine et à la bradykinine a été étudiée en chambres d’organe. Nous avons noté une amélioration de la relaxation de l’endothélium à la bradykinine et à l’acétylcholine dans le groupe avec inhalation de milrinone avec le nébulisateur ultrasonique. Dans la deuxième étude, une analyse rétrospective de 60 patients à haut risque chirurgical atteints d’HTP et opérés à l’Institut de Cardiologie de Montréal à été effectuée. Deux groupes ont été comparés : (1) 40 patients ayant reçu la combinaison de milrinone et d’époprosténol inhalés avant la CEC (groupe traitement) et (2) 20 patients avec des caractéristiques préopératoires n’ayant reçu aucun traitement inhalé avant la CEC (groupe contrôle). Nous avons observé que les besoins en support pharmacologique vasoactif était réduit à 12 heures et à 24 heures postopératoires dans le groupe traitement. L’utilisation de la nébulisation ultrasonique a un impact favorable sur l’endothélium de l’artère pulmonaire après la CEC lorsque comparée à la nébulisation standard à simple jet. Le traitement préventif des patients atteints d’HTP avec la combinaison de milrinone et d’époprosténol inhalés avant la CEC est associé avec une diminution importante des besoins de support vasoactif aux soins intensifs dans les 24 premières heures après la chirurgie. / Cardiopulmonary bypass (CPB) triggers a systemic inflammatory response, an ischemia-reperfusion (I-R) injury and endothelial dysfunction in the pulmonary circulation. Pulmonary hypertension (PH) is a consequence of this insult. The latter increases right ventricle work and may cause difficult separation from cardiopulmonary bypass (CPB) and increased vasoactive requirements after cardiac surgery. Administration of inhaled milrinone or epoprostenol has been shown to reduce endothelial dysfunction in the pulmonary artery. The aim of this work is to evaluate different nebulisators for the administration of milrinone and to evaluate the effect of pre-emptive treatment with inhaled milrinone and epoprostenol on postoperative outcome in cardiac surgery. Two different studies were done. In the first, three groups of swine were compared: (1) ultrasonic nebulisator inhaled milrinone group; CPB and reperfusion preceded by 2.5 mg inhaled milrinone, (2) simple jet nebulisator inhaled milrinone group; CPB and reperfusion preceded by 2.5 mg inhaled milrinone, and (3) control group; CBP 90 minutes followed by 60 minutes of reperfusion without treatment. During the procedure, hemodynamic, biochemical and hematologic parameters were measured. After sacrifice, pulmonary arterial endothelium-dependent relaxations to acetylcholine and bradykinin were studied in organ chamber experiments. There was a greater improvement in endothelium-dependent relaxations to bradykinin and acetylcholine in the ultrasonic nebuliser inhaled milrinone group compared with the control group and the simple jet nebulisator inhaled milrinone group. In the second study, a retrospective analysis of 60 high-risk surgical patients with PH operated at the Montreal Heart Institute was conducted. Two groups were compared: (1) 40 patients received both inhaled milrinone and inhaled epoprostenol before CPB (treatment group); (2) 20 patients with equivalent preoperative data did not receive any inhaled medication before CPB during the same period (control group). Post-operative vasoactive requirement was reduced at 12 hours and 24 hours post-operatively in the treatment group. Use of ultrasonic nebulisation has a favourable impact on the pulmonary endothelial dysfunction induced by CPB when compared to the simple jet nebulisation traditionally used. Pre-emptive treatment of PH with a combination of inhaled milrinone and epoprostenol prior to CPB was associated with a significant reduction in vasoactive support in the intensive care unit during the first 24 hours after cardiac surgery.