Intra-aortic balloonpump (IABP) counterpulsation therapy is a volume displacement device designed to provide partial assistance to the left ventricle of the heart. Critical care nurses are expected to manage IABP therapy. It is therefore important that the critical care nurse has the knowledge to manage IABP therapy in a safe and therapeutic manner. The question arises: does the critical care nurse have the knowledge to manage IABP therapy? The purpose of this research study is to explore and describe the knowledge of the critical care nurse regarding the management of IABP therapy. The design of this research study is a quantitative, descriptive and contextual study, in which a sample survey was performed, using a questionnaire (based on a literature study) under controlled conditions. The knowledge of the majority of critical care nurses tested was found to be insufficient. Safe management guidelines and in-service training have been proposed to improve the situation. / lntra-aortiese ballonpomp (IABP) teenpulsasie terapie is 'n volume verplasings apparaat, antwerp om gedeeltelike ondersteuning aan die linker ventrikel van die hart te bied. Kritiekesorgverpleegkundiges is verantwoordelik vir die hantering van rASP terapie. Die vraag ontstaan: beskik die kritiekesorgverpleegkundige oor voldoende kennis rakende die hantering van IABP terapie? Die doel van hierdie studie is om die kennis van kritiekesorgverpleegkundiges te ondersoek en te beskryf rakende die hantering van IABP terapie. Die resultate van hierdie navorsingstudie dui daarop dat die meerderheid kritiekesorgverpleegkundiges wat getoets was oor onvoldoende kennis beskik ten opsigte van IABP terapie. Formulering van riglyne en indiensopleiding is aanbeveel om hierdie situasie te verbeter. Die navorsingsontwerp is kwantitatief, beskrywend en kontekstueel van aard, waartydens 'n gerieflikheidsteekproeftrekking gedoen is, met gebruik van 'n vraelys (gebasseer op 'n literatuurstudie) onder gekontrolleerde toestande. / Health Studies / M.A. (Nursing Science)

UA Open Access Publishing Fund / Background: The use of intra-aortic balloon pump (IABP) via the trans-femoral approach has been established for hemodynamic support in patients undergoing high-risk percutaneous coronary intervention (PCI). However, there are various challenges associated with its use, especially in patients with aortoiliac occlusive arterial disease. Case presentation: We describe a case of high-risk PCI with IABP support complicated by intra-procedural detection of severe abdominal aortic stenosis that was successfully overcome with angioplasty of the stenotic lesion. Conclusions: Our report highlights distal abdominal aortic stenosis as a potential barrier to successful PCI with IABP support, and angioplasty as an effective means to overcome it.

Intra-aortic balloonpump (IABP) counterpulsation therapy is a volume displacement device designed to provide partial assistance to the left ventricle of the heart. Critical care nurses are expected to manage IABP therapy. It is therefore important that the critical care nurse has the knowledge to manage IABP therapy in a safe and therapeutic manner. The question arises: does the critical care nurse have the knowledge to manage IABP therapy? The purpose of this research study is to explore and describe the knowledge of the critical care nurse regarding the management of IABP therapy. The design of this research study is a quantitative, descriptive and contextual study, in which a sample survey was performed, using a questionnaire (based on a literature study) under controlled conditions. The knowledge of the majority of critical care nurses tested was found to be insufficient. Safe management guidelines and in-service training have been proposed to improve the situation. / lntra-aortiese ballonpomp (IABP) teenpulsasie terapie is 'n volume verplasings apparaat, antwerp om gedeeltelike ondersteuning aan die linker ventrikel van die hart te bied. Kritiekesorgverpleegkundiges is verantwoordelik vir die hantering van rASP terapie. Die vraag ontstaan: beskik die kritiekesorgverpleegkundige oor voldoende kennis rakende die hantering van IABP terapie? Die doel van hierdie studie is om die kennis van kritiekesorgverpleegkundiges te ondersoek en te beskryf rakende die hantering van IABP terapie. Die resultate van hierdie navorsingstudie dui daarop dat die meerderheid kritiekesorgverpleegkundiges wat getoets was oor onvoldoende kennis beskik ten opsigte van IABP terapie. Formulering van riglyne en indiensopleiding is aanbeveel om hierdie situasie te verbeter. Die navorsingsontwerp is kwantitatief, beskrywend en kontekstueel van aard, waartydens 'n gerieflikheidsteekproeftrekking gedoen is, met gebruik van 'n vraelys (gebasseer op 'n literatuurstudie) onder gekontrolleerde toestande. / Health Studies / M.A. (Nursing Science)

La traumatologie est la première cause de mortalité chez les sujets de moins de 40 ans dans les pays industrialisés. Le choc hypovolémique lié à une hémorragie du tronc est une cause fréquente de décès, à la fois sur les lieux de l’accident mais également pendant la prise en charge pré-hospitalière et intra-hospitalière. L’existence d’un hémopéritoine est un facteur de sous estimation du traumatisé grave.Le contrôle lésionnel, mieux connu sous les anglicismes « damage control ressucitation » et « damage control surgery », est le paradigme moderne de la prise en charge du choc hémorragique d’origine traumatique. Il comprend une mise en condition minimaliste privilégiant la réalisation d’une hémostase chirurgicale précoce et rapide, suivie d’une réanimation intensive associant transfusion massive, réchauffement et optimisation de la coagulation. Le traitement chirurgical exhaustif des lésions traumatiques est différé au delà de la période d’instabilité.Chez le blessé hémorragique agonique, la thoracotomie de ressuscitation avec clampage de l’aorte thoracique est une pratique courante mais dont les bases factuelles ne sont pas bien établies. En revanche en pathologie artérielle, la voie d’abord endovasculaire a très largement fait preuve de son efficacité.Nous avons émis l’hypothèse qu’un clampage aortique endovasculaire de l’aorte thoracique par voie rétrograde est possible et que cette technique améliore le profil hémodynamique dans le territoire myocardique et cérébral tout en augmentant la survie en cas de choc hémorragique lié à un traumatisme abdominal.Nos résultats suggèrent que cette technique de sauvetage est efficace, même s’il semble exister des limites corrélées à la durée de l’ischémie/reperfusion viscérale et médullaire. / Trauma is the leading cause of mortality in industrialized countries for people aged below 40 years. Fifty percent of the pre hospital and in hospital mortality from severe blunt and penetrating abdominal traumas is due to an hemorrhagic shock. Peritoneal bloody effusion is the main reason to under estimate the seriousness of trauma.Damage control resuscitation (DCR) and damage control surgery (DCS) typify the current paradigm of hemorrhagic torso trauma management. Damage control includes a basic pre operative management before a short surgical control of bleeding followed by intensive resuscitation care based on massive blood transfusion, palliation of hypothermia and correction of biological coagulation disorders. According to this strategy, the curative surgical treatment is postponed until the patient has been stabilized.Some authors have reported on the efficacy of resuscitation thoracotomy with aortic crossclamping in the emergency room in patients with severe abdominal trauma . However, the end results of such a procedure are contrasted and its use is still debated. More recently, endovascular approach has emerged in the management algorithm of some vascular emergencies. We hypothesized that an endovascular retrograde occlusion of the thoracic aorta would be a safe and efficient to preserve hemodynamic profile in cardiac and cerebral area, and to improve survival in case of uncontrolled hemorrhagic shock caused by an abdominal trauma.Our results sustain this hypothesis, even if its benefits seem time-limited, according to the medullar and visceral side-effects of ischemia/reperfusion.

M.Cur. / The intra-aortic balloon pump is a volume displacement device that is used to provide partial support to the left ventricle. The IABP is an effective and general used circulatory support device. The nursing of a patient on IABP therapy requires demonstration of specific clinical competence by the critical care nurse. Clinical competence is defined as the ability of the critical care nurse to integrate his/her knowledge, skills and values and to demonstrate it during nursing of a patient on IABP with the aim to promote the patient's health. The aim of this research had been to evaluate the clinical competence of the critical care nurse during the nursing of a patient on IABP, and to make recommendations according to that regarding education, the practice and research. The relationship between the components of clinical competence namely knowledge, skills and values that were set as aim, were also established. A quantitative, contextual, descriptive, correlational research design had been used in the study to compile a self-developed evaluation instrument that had been used to evaluate the clinical competence of the critical care nurse. The evaluation instrument consisted of a questionnaire that evaluated the knowledge of the critical care nurse, a check list that evaluated the skills of the critical care nurse and a semantic differential scale that evaluated the values of the critical care nurse during the nursing of a patient on IABP therapy. After the data was analyzed, it appeared that critical care nurses don't possess the necessary knowledge and skills to nurse patients on IABP, and as such are not clinically competent to nurse patients on IABP. iii Recommendations were made regarding education, the practice and research in order to improve the clinical competence of critical care nurses during the nursing of a patient on IABP therapy

INTRODUÇÃO: O balão intra-aórtico (BIA) representa o mecanismo de assistência ventricular mais frequentemente utilizado em pacientes com insuficiência cardíaca (IC), no Brasil. OBJETIVO: Neste trabalho, avaliamos a ação do BIA sobre o fluxo sanguíneo carotídeo e braquial, além do seu efeito sobre os marcadores de perfusão tecidual e sobre o peptídeo natriurético cerebral (BNP). MÉTODOS: Entre julho de 2006 e maio de 2009, 33 pacientes foram avaliados, sendo 10 excluídos. Os pacientes foram inicialmente mantidos com o BIA em modo 1:1, com insuflação máxima, para a fase inicial do estudo (condição 1). Realizou-se coleta de gasometria arterial, venosa central e BNP (condição EXA1). Foi realizada ultrassonografia vascular de alta definição, para captação de imagens das curvas de velocidade de fluxo sanguíneo, e medida dos diâmetros arteriais sistólico e diastólico (condição MD1). Em seguida, foi avaliada a resposta vascular frente à hiperemia reativa (condição HR1). Realizado o estudo na condição 1, o BIA foi modificado para 1:3 com insuflação mínima (condição 2) e todos os exames laboratoriais (condição EXA 2) e ultrassonográficos (condição MD2 e condição HR2) foram repetidos. Após a condição 2, passou-se à condição 3, na qual o BIA foi novamente modificado para a assistência 1:1, com insuflação máxima. Da mesma forma que nas condições anteriores, foram realizados exames laboratoriais (condição EXA 3) e a ultrassonografia (condição MD3 e HR3). A avaliação estatística foi realizada através da análise de variância para medidas repetidas e o uso do teste não paramétrico de Friedman. RESULTADOS: A idade média dos pacientes selecionados foi de 49,7 ± 13 anos, sendo 17 (74%) do sexo masculino e 6 (26%) do sexo feminimo. Quanto à etiologia, 9 (39%) pacientes eram portadores de miocardiopatia isquêmica, 8 (34%) miocardiopatia dilatada idiopática, 4 (17%) tinham etiologia chagásica e 2 (8%) por valvopatias. A fração de ejeção, estimada pelo ecocardiograma variou de 14 a 40%, com Resumo média de 22 +-8%. Nove pacientes (39%) encontravam-se em fila para transplante cardíaco, no momento da inclusão no protocolo, e a mortalidade durante a internação foi de 60,8%. Analisados os dados laboratoriais, não houve, entre as três medidas realizadas, diferença com significância estatística nos valores de bicarbonato arterial (BIC), assim como, nos valores de excesso de base (BE). Também não detectamos mudanças na saturação venosa central de oxigênio (SVcO2), no nível sérico de BNP e no gradiente venoarterial de CO2(DeltaPCO2). Os resultados das análises da velocidade de fluxo, índice de fluxo carotídeo e integral velocidade-tempo na condição MD1, MD2 e MD3 não revelaram diferenças estatisticamente significantes. Analisado o território braquial, considerando a velocidade de fluxo braquial não houve diferença entre a condição MD1 e a condição MD2 e entre a condição MD1 e a condição MD3. Entretanto, identificamos diferença entre as condições MD2 e MD3 (p=0,01). Não encontramos diferença com significância entre as três condições considerando o índice de fluxo e a integral velocidade-tempo. Na prova de hiperemia reativa não encontramos alteração entre as condições HR1, HR2 e HR3, quando avaliamos a velocidade de fluxo, o índice de fluxo e a integral velocidade-tempo. A dilatação fluxo mediada da artéria braquial (DILA) encontrava-se alterada desde o momento inicial, porém o protocolo não revelou alterações entre HR1, HR2 e HR3. CONCLUSÃO: Em pacientes com insuficiência cardíaca, a assistência com o BIA não modificou o fluxo sanguíneo regional em território cerebral e muscular esquelético avaliados pelo fluxo da carótida e artéria braquial, respectivamente. Da mesma forma, não houve alteração da perfusão tecidual e função cardíaca avaliados pelos marcadores do metabolismo oxidativo e sobrecarga hídrica utilizados. A função endotelial avaliada na condição de duplo pulso de fluxo da artéria braquial propiciada pela assistência circulatória do BIA evidenciou-se alterada com dimunuição da reatividade vascular / BACKGROUND: The intra-aortic balloon (IAB) represents the mechanism of ventricular assist more often used in patients with heart failure (HF) in our midst. OBJECTIVE: In this study, we evaluated the action of the IAB on the carotid and brachial blood flow, in addition to its effect on markers of tissue perfusion and the brain natriuretic peptide (BNP). METHODS: Between July 2006 and May 2009, 33 patients were evaluated, 10 were excluded. Patients were initially maintained with the IAB in 1:1 mode with maximum insufflation, for the initial phase of the study (condition 1). Held collection of arterial and central venous blood gases, and BNP (condition EXA1). Vascular ultrasonography was performed in high definition, to capture images of the curves of blood flow velocity, and measurement of systolic and diastolic arterial diameters (condition MD1). Then we evaluated the vascular responses to reactive hyperemia (condition HR1). Conducted the study in condition 1, the IAB was changed to 1:3 with minimal insufflation (condition 2) and all laboratory tests (condition EXA 2) and ultrasound (condition MD2 and HR2) were repeated. After the second condition, the IAB was again modified to 1:1, with maximum insufflation (condition 3). Similarly to the previous conditions, laboratory tests (condition EXA 3) and ultrasound (condition MD3 and HR3) were performed. Statistical evaluation was performed by analysis of variance for repeated measures and the use of Friedman nonparametric test. RESULTS: The mean age of the selected patients was 49.7 +- 13 years, 17 (74%) males and 6 (26%) were females. Concerning etiology, 9 (39%) patients had ischemic cardiomyopathy, 8 (34%), idiopathic dilated cardiomyopathy, 4 (17%) had Chagas disease and 2 were (8%) related to valvulopathy. Ejection fraction estimated by echocardiography ranged from 14 to 40%, with a mean of 22 +- 8%. Nine patients (39%) were in line for a heart transplant at the time of inclusion in the protocol and mortality during hospitalization was 60.8%. Analyzed laboratory data, among the three measurements, there was not statistically significant difference in the values of arterial bicarbonate (BIC) and base excess (BE). We also did not detect changes in central venous oxygen saturation (SCVO2) or in serum BNP level and venoarterial carbon dioxide gradient (DeltaPCO2). The results of the analysis of carotid flow velocity, index of carotid flow and velocity time integral in condition MD1, MD2 and MD3 revealed no statistically significant difference. Examined the brachial territory, there was no difference between the condition MD1 and MD2 and between MD1 and MD3 considering the flow velocity. However, there was difference between conditions MD2 and MD3 (p = 0.01). We found no significant difference between the three conditions considering the brachial flow index and velocity time integral. The flow-mediated dilation of the brachial artery (FMD) found itself changed from the initial moment, but the protocol does not reveal changes between HR1, HR2 and HR3. CONCLUSION: In heart failure patients, assistance with the BIA did not alter regional blood flow in brain and skeletal muscle territory assessed by flow carotid and brachial artery, respectively. Likewise, there was no change in tissue perfusion and cardiac function assessed by markers of oxidative metabolism and fluid overload used. Endothelial function evaluated on condition of dual pulse brachial artery flow provided by BIA circulatory support showed up changed with decreased vascular reactivity

This thesis is focused on the issues linked with providing highly specialized care to critically ill patients with intra-aortic balloon pump (IABP) in intensive care units. IABP helps these patients overcome period of acute phase of heart failure or overcome period of time necessary before definitive intervention or surgical solution. A nurse has an irreplaceable role from the very beginning of patient's preparation before insertion of mechanical support (psychological as well as physical), assumes the assistance and instrumentation during insertion of heart support, observation during counterpulsation to psychological support of the patient leading to disconnection (weaning). This thesis is divided into two parts. Theoretical part is organized in several theme units focused on description and method principles, main indications, contraindications, and complications occuring with counterpulsation. The next part is dedicated to nurse's role in the problematics of saturation of bio-psycho-social needs of IABP patients. And the last part characterizes the specifics of intensive care. The core of practical part was qualitative research as per defined goals. The main objective was to map demand for quality nursing care in connection with IABP. This aim was reached through definition of four sub-aims and five research questions. The research questions were focused firstly on knowledge preconditions of nurses and problematic areas of care for IABP patients. Secondly, research effort was focused on the area of insufficient needs of patients in the bio-psycho-social area and on quality of information provided to patients. Imaginary centerpiece of research investigation consists of analysis of case studies of patiens, graphic visualisation of their thought map was used to survey the specifics of nursing care. For the evaluation of needs and mapping of patient's awareness the technique of individual half-structured interview with open questions was used. Same was used with nurses for mapping of problematic areas of nursing care. At the same time casuistry was formed as classical method of description followed by analysis of nursing case. Its meaning was to clarify optimization of means, processes and nursing interventions, i.e. mapping the specifics of nursing care of IABP patients. Research group consisted of patients selected intentionally with regards to the research problematics. For a complex conseption of the research the group for qualitative investigation consisted of four patients of cardio-surgery unit and one patient of coronary unit. Research investigation was realized in coronary intensive care units in České Budějovice hospital and Faculty hospital Plzeň and in Cardio-surgery unit of FN Plzeň. Research group for investigation of nursing problematic was formed by nurses of coronary units and cardio-surgery units of above mentioned hospitals. Eight nurses participated in the interviews. The selection of nurses was finalized only after the research topics were developed in detail. At that time sample selection was not bringing any new information any more, hence theoretical saturation of factual reality was reached. Based on analysis of research results within the goal defined and focused on the level of nurses' theoretical knowledge of nursing patients during IABP therapy it was observed that even though nurse's knowledge is sufficient, it is also significantly inconsistent. Relatively vast reserves were found especially in the area of communication with patients, hence in complex care for patient's psychological state.

INTRODUÇÃO: O balão intra-aórtico (BIA) representa o mecanismo de assistência ventricular mais frequentemente utilizado em pacientes com insuficiência cardíaca (IC), no Brasil. OBJETIVO: Neste trabalho, avaliamos a ação do BIA sobre o fluxo sanguíneo carotídeo e braquial, além do seu efeito sobre os marcadores de perfusão tecidual e sobre o peptídeo natriurético cerebral (BNP). MÉTODOS: Entre julho de 2006 e maio de 2009, 33 pacientes foram avaliados, sendo 10 excluídos. Os pacientes foram inicialmente mantidos com o BIA em modo 1:1, com insuflação máxima, para a fase inicial do estudo (condição 1). Realizou-se coleta de gasometria arterial, venosa central e BNP (condição EXA1). Foi realizada ultrassonografia vascular de alta definição, para captação de imagens das curvas de velocidade de fluxo sanguíneo, e medida dos diâmetros arteriais sistólico e diastólico (condição MD1). Em seguida, foi avaliada a resposta vascular frente à hiperemia reativa (condição HR1). Realizado o estudo na condição 1, o BIA foi modificado para 1:3 com insuflação mínima (condição 2) e todos os exames laboratoriais (condição EXA 2) e ultrassonográficos (condição MD2 e condição HR2) foram repetidos. Após a condição 2, passou-se à condição 3, na qual o BIA foi novamente modificado para a assistência 1:1, com insuflação máxima. Da mesma forma que nas condições anteriores, foram realizados exames laboratoriais (condição EXA 3) e a ultrassonografia (condição MD3 e HR3). A avaliação estatística foi realizada através da análise de variância para medidas repetidas e o uso do teste não paramétrico de Friedman. RESULTADOS: A idade média dos pacientes selecionados foi de 49,7 ± 13 anos, sendo 17 (74%) do sexo masculino e 6 (26%) do sexo feminimo. Quanto à etiologia, 9 (39%) pacientes eram portadores de miocardiopatia isquêmica, 8 (34%) miocardiopatia dilatada idiopática, 4 (17%) tinham etiologia chagásica e 2 (8%) por valvopatias. A fração de ejeção, estimada pelo ecocardiograma variou de 14 a 40%, com Resumo média de 22 +-8%. Nove pacientes (39%) encontravam-se em fila para transplante cardíaco, no momento da inclusão no protocolo, e a mortalidade durante a internação foi de 60,8%. Analisados os dados laboratoriais, não houve, entre as três medidas realizadas, diferença com significância estatística nos valores de bicarbonato arterial (BIC), assim como, nos valores de excesso de base (BE). Também não detectamos mudanças na saturação venosa central de oxigênio (SVcO2), no nível sérico de BNP e no gradiente venoarterial de CO2(DeltaPCO2). Os resultados das análises da velocidade de fluxo, índice de fluxo carotídeo e integral velocidade-tempo na condição MD1, MD2 e MD3 não revelaram diferenças estatisticamente significantes. Analisado o território braquial, considerando a velocidade de fluxo braquial não houve diferença entre a condição MD1 e a condição MD2 e entre a condição MD1 e a condição MD3. Entretanto, identificamos diferença entre as condições MD2 e MD3 (p=0,01). Não encontramos diferença com significância entre as três condições considerando o índice de fluxo e a integral velocidade-tempo. Na prova de hiperemia reativa não encontramos alteração entre as condições HR1, HR2 e HR3, quando avaliamos a velocidade de fluxo, o índice de fluxo e a integral velocidade-tempo. A dilatação fluxo mediada da artéria braquial (DILA) encontrava-se alterada desde o momento inicial, porém o protocolo não revelou alterações entre HR1, HR2 e HR3. CONCLUSÃO: Em pacientes com insuficiência cardíaca, a assistência com o BIA não modificou o fluxo sanguíneo regional em território cerebral e muscular esquelético avaliados pelo fluxo da carótida e artéria braquial, respectivamente. Da mesma forma, não houve alteração da perfusão tecidual e função cardíaca avaliados pelos marcadores do metabolismo oxidativo e sobrecarga hídrica utilizados. A função endotelial avaliada na condição de duplo pulso de fluxo da artéria braquial propiciada pela assistência circulatória do BIA evidenciou-se alterada com dimunuição da reatividade vascular / BACKGROUND: The intra-aortic balloon (IAB) represents the mechanism of ventricular assist more often used in patients with heart failure (HF) in our midst. OBJECTIVE: In this study, we evaluated the action of the IAB on the carotid and brachial blood flow, in addition to its effect on markers of tissue perfusion and the brain natriuretic peptide (BNP). METHODS: Between July 2006 and May 2009, 33 patients were evaluated, 10 were excluded. Patients were initially maintained with the IAB in 1:1 mode with maximum insufflation, for the initial phase of the study (condition 1). Held collection of arterial and central venous blood gases, and BNP (condition EXA1). Vascular ultrasonography was performed in high definition, to capture images of the curves of blood flow velocity, and measurement of systolic and diastolic arterial diameters (condition MD1). Then we evaluated the vascular responses to reactive hyperemia (condition HR1). Conducted the study in condition 1, the IAB was changed to 1:3 with minimal insufflation (condition 2) and all laboratory tests (condition EXA 2) and ultrasound (condition MD2 and HR2) were repeated. After the second condition, the IAB was again modified to 1:1, with maximum insufflation (condition 3). Similarly to the previous conditions, laboratory tests (condition EXA 3) and ultrasound (condition MD3 and HR3) were performed. Statistical evaluation was performed by analysis of variance for repeated measures and the use of Friedman nonparametric test. RESULTS: The mean age of the selected patients was 49.7 +- 13 years, 17 (74%) males and 6 (26%) were females. Concerning etiology, 9 (39%) patients had ischemic cardiomyopathy, 8 (34%), idiopathic dilated cardiomyopathy, 4 (17%) had Chagas disease and 2 were (8%) related to valvulopathy. Ejection fraction estimated by echocardiography ranged from 14 to 40%, with a mean of 22 +- 8%. Nine patients (39%) were in line for a heart transplant at the time of inclusion in the protocol and mortality during hospitalization was 60.8%. Analyzed laboratory data, among the three measurements, there was not statistically significant difference in the values of arterial bicarbonate (BIC) and base excess (BE). We also did not detect changes in central venous oxygen saturation (SCVO2) or in serum BNP level and venoarterial carbon dioxide gradient (DeltaPCO2). The results of the analysis of carotid flow velocity, index of carotid flow and velocity time integral in condition MD1, MD2 and MD3 revealed no statistically significant difference. Examined the brachial territory, there was no difference between the condition MD1 and MD2 and between MD1 and MD3 considering the flow velocity. However, there was difference between conditions MD2 and MD3 (p = 0.01). We found no significant difference between the three conditions considering the brachial flow index and velocity time integral. The flow-mediated dilation of the brachial artery (FMD) found itself changed from the initial moment, but the protocol does not reveal changes between HR1, HR2 and HR3. CONCLUSION: In heart failure patients, assistance with the BIA did not alter regional blood flow in brain and skeletal muscle territory assessed by flow carotid and brachial artery, respectively. Likewise, there was no change in tissue perfusion and cardiac function assessed by markers of oxidative metabolism and fluid overload used. Endothelial function evaluated on condition of dual pulse brachial artery flow provided by BIA circulatory support showed up changed with decreased vascular reactivity

Orientador: Desanka Dragosavac / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-23T05:41:33Z (GMT). No. of bitstreams: 1 Fusatto_HelenaAmaralGoncalves_M.pdf: 1612494 bytes, checksum: 6a0555f472010bd45b7020a576214e54 (MD5) Previous issue date: 2013 / Resumo: Introdução: A disfunção pulmonar é frequente no pós operatório de cirurgias cardíacas com o emprego da circulação extracorpórea e pode contribuir para o aumento do tempo de ventilação mecânica (VM). Além disso, fatores pré e perioperatórios tais como idade avançada, gênero feminino, baixa fração de ejeção, síndrome de baixo débito cardíaco, tempo de circulação extracorpórea prolongado (CEC) e uso do balão intra-aórtico (BIA) podem retardar a extubação bem como contribuir para o insucesso deste procedimento. O tempo aumentado de ventilação mecânica está associado à maior tempo de permanência na unidade de terapia intensiva (UTI) e mortalidade hospitalar. Objetivos: Avaliar os parâmetros de troca gasosa e fatores pré e perioperatórios associados ao tempo prolongado de VM, internação na UTI, insucesso da extubação e mortalidade hospitalar em pacientes submetidos à cirurgia eletiva de revascularização do miocárdio com ou sem reconstrução do ventrículo esquerdo que utilizaram BIA no período intra e pós operatório. Método: Estudo observacional no qual foram analisadas variáveis respiratórias, clínicas, demográficas e cirúrgicas que posteriormente foram relacionadas com os seguintes desfechos: tempo de ventilação mecânica, tempo de internação na UTI, insucesso na extubação e mortalidade hospitalar. Resultados: Foram avaliados 39 pacientes com idade média 61,2 anos e vinte e cinco dos 39 (64,1%) pacientes eram do gênero masculino. A disfunção pulmonar esteve presente no pós operatório imediato até o terceiro pós operatório, caracterizada por síndrome do desconforto respiratório agudo (SDRA) de grau leve. O tempo médio de VM foi de 94,4 horas e apresentou influência do tempo de uso do BIA e PaO2/FiO2 no POI, na análise univariada e na análise múltipla acrescentou-se o gênero feminino e o tabagismo. O tempo médio de internação na UTI foi de 15,1 dias e as variáveis que mais influenciaram este desfecho foram APACHE II e tempo de uso de BIA nas análises univariada e múltipla. O insucesso na extubação ocorreu em 18 (46,15%) dos 39 pacientes estudados e nenhuma das variáveis analisadas apresentaram influência sobre este evento. O óbito ocorreu em 19 (48,72%) dos 39 pacientes e apresentou forte influencia do APACHE II seguido do insucesso da extubação. Conclusão: A disfunção pulmonar esteve presente do pós operatório imediato até o terceiro pós operatório. O tempo de VM foi influenciado pelo gênero feminino, tabagismo, tempo de uso do BIA e PaO2/FiO2 no POI. O tempo de internação na UTI foi influenciado pelo APACHE II e tempo de uso do BIA. A mortalidade foi influenciada pelo APACHE II seguido do insucesso na extubação, e este último, quando analisado como desfecho não obteve influência das variáveis estudadas / Abstract: Introduction: Pulmonary dysfunction is common in the postoperative period of cardiac surgery with extracorporeal circulation and may contribute to the increased length of mechanical ventilation (MV). Furthermore, perioperative factors such as older age, female gender, low ejection fraction, low cardiac output syndrome, prolonged cardiopulmonary bypass time (CPB) and use of intra-aortic balloon pump (IABP) may delay extubation and contribute to the failure of this procedure. The increased time on mechanical ventilation is associated with increased length of stay in the intensive care unit (ICU) and hospital mortality. Objective: The aim of this study was to evaluate the respiratory function and perioperative factors associated with prolonged mechanical ventilation, ICU stay, extubation failure and mortality in patients undergoing elective coronary artery bypass grafting with or without reconstruction of the left ventricle that used BIA in intraoperative and postoperative. Methods: Observational study analyzed respiratory, surgical and clinical demographic that later were related to the following outcomes: duration of mechanical ventilation, length of stay in the Intensive Care Unit, extubation failure and mortality. Results: We evaluated 39 patients with mean age 61.2 years and 25 of 39 (64.1%) were male. Pulmonary dysfunction this gift from immediate postoperative until the third postoperative characterized by mild ARDS. The mean duration of MV was 94.4 hours and was influenced by the time of use of BIA and PaO2/FiO2 in the IPO, in univariate and multivariate analysis added the female gender and smoking. The mean ICU stay was 15.1 days and the variables that most influenced this outcome were APACHE II and time of use of BIA in univariate and multivariate analyzes. The failure of extubation occurred in 18 (46.15%) of 39 patients and none of the variables had influence on this event. The death occurred in 19 (48.75%) of 39 patients and showed a strong influence of the APACHE II followed extubation failure. Conclusion: Pulmonary dysfunction was present in the immediate postoperative period until the third postoperative. The MV time was influenced by the female, smoking, time of use of BIA and PaO2/FiO2 in POI. The length of ICU stay was influenced by APACHE II and age of the BIA. Mortality was influenced by APACHE II followed the failure of extubation, and the latter, when analyzed as an outcome not achieved influence of the parameters / Mestrado / Fisiopatologia Cirúrgica / Mestra em Ciências

Introdução: A cirurgia cardíaca resulta em taxa considerável de complicações neurológicas, incluindo delirium, disfunção cognitiva e acidente vascular cerebral isquêmico. Supõe que a fisiopatologia envolva embolia, aterotrombose, hipofluxo, redução do débito cardíaco e alterações da autorregulação cerebral. O balão de contrapulsação intra-aórtico (BIA) é um dispositivo de assistência circulatória comumente utilizado no perioperatório de pacientes de alto risco com o objetivo de otimização do débito cardíaco e da perfusão coronária. Apesar do benefício hemodinâmico do BIA, não é conhecido seu efeito na hemodinâmica encefálica. Objetivo: Avaliar os efeitos do BIA na hemodinâmica encefálica em pacientes de alto risco submetido a cirurgia cardíaca com circulação extracorpórea (CEC). Métodos: Trata-se de um subestudo do estudo clínico prospectivo e randomizado \"Balão de contra-pulsação intra-aórtico eletivo em pacientes de alto risco submetidos a cirurgia cardíaca\", realizado no Instituto do coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 2014 e 2016. Dos 181 pacientes incluídos no estudo randomizado, 67 pacientes foram incluídos no subestudo. Os pacientes eram adultos, submetidos a cirurgia cardíaca de revascularização miocárdica (RM) com fração de ejeção menor ou igual a 40% e/ou EuroScore maior ou igual a 6. Os mesmos foram randomizados para uso do BIA logo após a indução anestésica ou para grupo controle. A velocidade de fluxo sanguíneo cerebral (VFSC) pelo ultrassom Doppler transcraniano e a pressão arterial (PA) pelo Finometer foram continuamente gravados por 5 minutos antes da cirurgia (T1), 24h após (T2) e 7 dias após (T3). O índice de autorregulação (ARI) foi estimado através da resposta ao degrau da VFSC a mudanças na PA, derivados da análise da função de transferência. As seguintes complicações clínicas neurológicas foram avaliadas: delirium, disfunção cognitiva e acidente vascular cerebral isquêmico. Resultados: Dos pacientes incluídos no estudo, 34 foram alocados para a estratégia de uso profilático do balão intra-aórtico e 33 para a estratégia controle. Não houve diferenças significativas entre os grupos BIA e controle respectivamente, nos três tempos de avaliação, em relação ao ARI (T1 - 5,5 ± 1,9 vs 5,7 ± 1,7; T2 - 4,0 ± 1,9 vs 4,1 ± 1,6; T3 - 5,7 ± 2,0 vs 5,7 ± 1,6, P= 0,978) e em relação à VFSC (T1 - 57,3 ± 19,4 vs 59,3 ± 11,8; T2 - 74,0 ± 21,6 vs 74,7 ± 17,5; T3 - 71,1 ± 21,3 vs 68,1 ± 15,1; P=0,952). O grupo BIA e o grupo controle apresentaram incidência semelhante de complicações neurológicas (delirium na unidade de terapia intensiva - 26,5% vs 24,2%, P=0,834, acidente vascular cerebral isquêmico - 3,0% vs 2,9%, P=1,00, e declínio cognitivo pós-operatório através das escalas Mini Mental State Examination MMSE - 16,7% vs 40,7%; P= 0,073 e Avaliação Cognitiva Montreal MoCA - 79,16% vs 81,5%; P= 1,000). Conclusões: O uso profilático do BIA em pacientes de alto risco submetidos à cirurgia de revascularização do miocárdio não altera a hemodinâmica encefálica e não está associado ao aumento de complicações neurológicas como delirium, declínio cognitivo e acidente vascular cerebral isquêmico / Introduction: Cardiac surgery is associated with a high incidence of neurologic complications, such as delirium, cognitive decline and stroke. The pathophysiology probably involves embolism, thrombosis, decreased cardiac output and abnormalities in cerebral autoregulation. The intraaortic balloon pump (IABP) is an assist device commonly in high-risk patients undergoing cardiac surgery aiming to increase the cardiac output and to improve the coronary perfusion. However, the effect of the IABP on the cerebral hemodynamic is unknown. Objectives: To assess the effect of IABP on cerebral hemodynamics in high-risk patients undergoing cardiac surgery with cardio-pulmonary bypass (CPB). Methods: This is a substudy of the randomized controlled trial \"Intraaortic Balloon Counterpulsation in Patients Undergoing Cardiac Surgery (IABCS trial)\", performed at the Heart Institute/University of Sao Paulo, from 2014 to 2016. Of the 181 patients included in the IABCS, 67 were included if they were submitted to cardiac surgery and if they had one of these two criteria: left ventricular ejection fraction equal or lower than 40% and/or EuroSCORE equal or higher than 6. Patients were allocated to the strategy of prohylatic IABP after anesthesia induction or to control. Cerebral blood flow velocity (CBFV) through transcranial Doppler and blood pressure (BP) through Finometer or intra-arterial line were continuously recorded over 5 minutes preoperatively (T1), after 24h (T2) and 7 days after surgery (T3). Autoregulation index (ARI) was estimated from the CBFV response to a step change in BP derived by transfer function analysis. The following complications neurologic were evaluated: delirium, cognitive decline and stroke. Results: Of the included patients, 34 were allocated to the IABP group and 33 to control group. There were no significant differences between the IABP and the control respectively in the following parameters: ARI (T1 - 5.5 ± 1.9 vs 5.7 ± 1.7; T2 - 4.0 ± 1.9 vs 4.1 ± 1.6; T3 - 5.7 ± 2.0 vs 5.7 ± 1.6, P= 0.978), CBFV (T1 - 57.3 ± 19.4 vs 59.3 ± 11.8; T2 - 74.0 ± 21.6 vs 74.7 ± 17.5; T3 - 71.1 ± 21.3 vs 68.1 ± 15.1; P=0.952). Both groups (IABP and control) had similar incidence of neurological complications (delirium - 26.5% vs 24.2%, P=0.834, stroke - 3.0% vs 2.9%, P=1.00, and cognitive decline through the scales Mini Mental State Examination MMSE - 16,7% vs 40,7%; P= 0.073 and Montreal Cognitive Assessment MoCA - 79.16% vs 81.5%; P= 1.000). Conclusions: The prophylactic use of IABP in high-risk patients undergoing cardiac surgery does not change the cerebral hemodynamic and is not associated with higher incidence of neurologic complications such as delirium, cognitive decline and stroke