INTRODUÇÃO: Diferentes parâmetros hemodinâmicos, incluindo os indicadores estáticos de pré-carga cardíaca como o índice de volume diastólico final ventrículo direito (IVDFVD) e parâmetros dinâmicos como a variação de pressão de pulso (VPP) têm sido usados na tomada de decisão para considerar o processo da expansão volêmica em pacientes em estado grave. O objetivo deste estudo foi comparar a reanimação por fluidos guiados tanto por VPP ou IVDFVD após choque hemorrágico induzido experimentalmente. MÉTODO: vinte e seis suínos anestesiados e ventilados mecanicamente foram alocados em três grupos: controle (Grupo I), VPP (Grupo II) e IVDFVD (Grupo III). Foi induzido choque hemorrágico por retirada de sangue até atingir a pressão arterial média de 40mmhg, que foi mantida por 60 minutos. Parâmetros foram medidos no tempo basal (B), no tempo do choque (Choque 0), sessenta minutos depois do choque (Choque 60), imediatamente depois da ressuscitação com hidroxietilamido 6% (130/0. 4) (R0), uma hora (R60) e duas horas (R120) depois ressuscitação. Os pontos de avaliação da reanimação por fluidos foram determinados pelo retorno aos valores basais iniciais de VPP e IVDFVD. A análise estatística dos dados foi baseada em ANOVA para medidas repetidas seguidos pelo teste de Bonferroni (P<0.05%). RESULTADOS: O volume e tempo para ressuscitação foram maiores no grupo III do que no grupo II (Grupo III = 1305±331ml e Grupo II = 965±245ml; p<0.05 e Grupo III = 24.8± 4.7min e Grupo II = 8.8 ± 1.3 min, p<0.01, respectivamente). Todos os parâmetros estáticos e dinâmicos, bem como os biomarcadores de oxigenação tecidual foram afetados pelo choque hemorrágico e quase todos os parâmetros foram totalmente restaurados após a reanimação em ambos os grupos. CONCLUSÃO: Neste estudo em modelo de choque hemorrágico, a reanimação guiada pelo VPP utilizou menor quantidade de fluido e menor quantidade de tempo do que quando guiado por IVDFVD derivado de cateter de artéria pulmonar. / INTRODUCTION: Different hemodynamic parameters, including static indicators of cardiac preload as right ventricular end-diastolic volume index (RVEDVI) and dynamic parameters as pulse pressure variation (PPV) have been used in the decision-making process regarding volume expansion in critically ill patients. The objective of this study was to compare fluid resuscitation guided by either PPV or RVEDVI after experimentally-induced hemorrhagic shock. METHODS: 26 anesthetized and mechanically ventilated pigs were allocated into control (Group-I), PPV (Group-II) and RVEDVI (Group- III). Hemorrhagic shock was induced by blood withdrawal to target mean arterial pressure of 40mmHg, maintained for 60 minutes. Parameters were measured at baseline, time of shock, sixty minutes after shock, immediately after resuscitation with hydroxyethyl starch 6% (130/0.4), one hour and two hours thereafter. The endpoint of fluid resuscitation was determined as the baseline values of PPV and RVEDVI. Statistical analysis of data was based on ANOVA for repeated measures followed by the Bonferroni test (P<0.05). RESULTS: Volume and time to resuscitation were higher in Group-III than in Group-II (Group-III = 1305±331ml and Group-II = 965±245ml; p<0.05 and Group-IIII = 24.8±4.7min and Group-II = 8.8±1.3 min, p<0.05, respectively). All static and dynamic parameters and biomarkers of tissue oxygenation were affected by hemorrhagic shock and nearly all parameters were restored after resuscitation in both groups. CONCLUSION: In the proposed model of hemorrhagic shock, resuscitation to the established endpoints was achieved within a smaller amount of time and with less volume when guided by PPV than when guided by pulmonary artery catheter-derived RVEDVI.

Diss. (sammanfattning) Linköping : Univ., 2002. / Härtill 5 uppsatser.

INTRODUÇÃO: Diferentes parâmetros hemodinâmicos, incluindo os indicadores estáticos de pré-carga cardíaca como o índice de volume diastólico final ventrículo direito (IVDFVD) e parâmetros dinâmicos como a variação de pressão de pulso (VPP) têm sido usados na tomada de decisão para considerar o processo da expansão volêmica em pacientes em estado grave. O objetivo deste estudo foi comparar a reanimação por fluidos guiados tanto por VPP ou IVDFVD após choque hemorrágico induzido experimentalmente. MÉTODO: vinte e seis suínos anestesiados e ventilados mecanicamente foram alocados em três grupos: controle (Grupo I), VPP (Grupo II) e IVDFVD (Grupo III). Foi induzido choque hemorrágico por retirada de sangue até atingir a pressão arterial média de 40mmhg, que foi mantida por 60 minutos. Parâmetros foram medidos no tempo basal (B), no tempo do choque (Choque 0), sessenta minutos depois do choque (Choque 60), imediatamente depois da ressuscitação com hidroxietilamido 6% (130/0. 4) (R0), uma hora (R60) e duas horas (R120) depois ressuscitação. Os pontos de avaliação da reanimação por fluidos foram determinados pelo retorno aos valores basais iniciais de VPP e IVDFVD. A análise estatística dos dados foi baseada em ANOVA para medidas repetidas seguidos pelo teste de Bonferroni (P<0.05%). RESULTADOS: O volume e tempo para ressuscitação foram maiores no grupo III do que no grupo II (Grupo III = 1305±331ml e Grupo II = 965±245ml; p<0.05 e Grupo III = 24.8± 4.7min e Grupo II = 8.8 ± 1.3 min, p<0.01, respectivamente). Todos os parâmetros estáticos e dinâmicos, bem como os biomarcadores de oxigenação tecidual foram afetados pelo choque hemorrágico e quase todos os parâmetros foram totalmente restaurados após a reanimação em ambos os grupos. CONCLUSÃO: Neste estudo em modelo de choque hemorrágico, a reanimação guiada pelo VPP utilizou menor quantidade de fluido e menor quantidade de tempo do que quando guiado por IVDFVD derivado de cateter de artéria pulmonar. / INTRODUCTION: Different hemodynamic parameters, including static indicators of cardiac preload as right ventricular end-diastolic volume index (RVEDVI) and dynamic parameters as pulse pressure variation (PPV) have been used in the decision-making process regarding volume expansion in critically ill patients. The objective of this study was to compare fluid resuscitation guided by either PPV or RVEDVI after experimentally-induced hemorrhagic shock. METHODS: 26 anesthetized and mechanically ventilated pigs were allocated into control (Group-I), PPV (Group-II) and RVEDVI (Group- III). Hemorrhagic shock was induced by blood withdrawal to target mean arterial pressure of 40mmHg, maintained for 60 minutes. Parameters were measured at baseline, time of shock, sixty minutes after shock, immediately after resuscitation with hydroxyethyl starch 6% (130/0.4), one hour and two hours thereafter. The endpoint of fluid resuscitation was determined as the baseline values of PPV and RVEDVI. Statistical analysis of data was based on ANOVA for repeated measures followed by the Bonferroni test (P<0.05). RESULTS: Volume and time to resuscitation were higher in Group-III than in Group-II (Group-III = 1305±331ml and Group-II = 965±245ml; p<0.05 and Group-IIII = 24.8±4.7min and Group-II = 8.8±1.3 min, p<0.05, respectively). All static and dynamic parameters and biomarkers of tissue oxygenation were affected by hemorrhagic shock and nearly all parameters were restored after resuscitation in both groups. CONCLUSION: In the proposed model of hemorrhagic shock, resuscitation to the established endpoints was achieved within a smaller amount of time and with less volume when guided by PPV than when guided by pulmonary artery catheter-derived RVEDVI.

<p>Ciljevi: U kliničkoj praksi se rutinski upotrebljava vizuelna metoda evaluacije TOF testa, koja ne pruža u potpunosti precizne podatke u periodu oporavka neuromi&scaron;ićne blockade. Neophodno je ispitati mogućnost upotrebe specifičnije i preciznije metode u TOF monitoring, kao &scaron;to je kvantitativna TOF metoda. Određivanje razlike između vrednosti T1 i T4 mi&scaron;ićnih kontrakcija, dobijenih kvantitativnom TOF metodom, može biti precizan pokazatelj prisustva neuromi&scaron;ićne blokade na testiranom mi&scaron;iću. Takođe, aplikacijom kvantitativne TOF metode, neophodno je utvrditi da li kod različitih mi&scaron;ića postoji različit period oporavka od prisustva neuromi&scaron;ićne blokade. Upotreba kvantitativne TOF metode, i poređenje T4 / T1 odnosa između različitih mi&scaron;ića, može biti pokazatelj postojanja razlika u oporavku od prisustva neuromi&scaron;ićne blokade. Materijal i metode: U istraživanju je analiziran oporavak od prisustva neromi&scaron;ićne blokade na m.abductor hallucis i m. interosseus dorsalis primus aplikacijom kvantitativnog TOF testa u toku ortopedskih hirur&scaron;kih procedura na kičmenom stubu uz upotrebu intraoperativnog neurofiziolo&scaron;kog monitoring kod 147 bolesnika. T4/T1 odnos je određen na testiranom mi&scaron;iću stopala i &scaron;ake, obavljena je klasifikacija ispitanika u odnosu na dozu neuromi&scaron;ićnog blokatora i proteklo vreme od apilikacije. Poređenjem T4/T1 odnosa između testiranih mi&scaron;ića utvrđene su razlike u oporavku od prisustva neuromi&scaron;ićne blokade. Vizuelnom TOF metodom je vr&scaron;ena procena neuromi&scaron;ićne blokade od strane anesteziologa, stimulacijom n.ulnaris i praćenjem kontrakcije m.adductor pollicis. Rezultati dobijeni vizuelnom TOF metodom su upoređeni sa rezultatima dobijenim kvantitativnom TOF metodom na m. interosseus dorsalis primus. Rezultati: Postoje značajne razlike u T4/T1 odnosu između testiranih mi&scaron;ića na stopalu i &scaron;aci (p&lt;0.05). T4/T1 odnos određen na m.abductor hallucis ima niže vrednosti, odnosno brži oporavak, u odnosu na m. interosseus dorsalis primus (p&lt;0.05). Kvantitativnom TOF metodom dobijeni su pouzdani rezultati o proceni neuromi&scaron;ićne blokade kod svih testiranih bolesnika, dok su vizuelnom TOF metodom dobijeni kod 40 % testiranih bolesnika. Rezultati pokazuju da postoje značajne razlike u pouzdanosti i preciznosti između kvantitativne i vizuelne TOF metode. Zaključak: Kvantitativna TOF metoda je klinički prihvatljiva i pouzdana metoda u proceni prisustva neuromi&scaron;ićne blokade. Razlike u oporavku od neuromi&scaron;ićne blokade uočene kod različitih mi&scaron;ića, ukazuju da je TOF monitoring neophodan na određenoj mi&scaron;ićnoj regiji koja pruža pouzdane i precizne podatke o neuromi&scaron;ićnoj blokadi regije na kojoj se hirur&scaron;ka procedura obavlja. Kvantitativna TOF metoda pruža preciznije podatke o stepenu prisustva neuromi&scaron;ićne blokade u odnosu na vizuelnu subjektivnu TOF metodu.</p> / <p>Purpose: In clinical practice routinely used method of TOF test is visual method of interpretation. This method does not provide completely reliable data in period of spontaneous recovery from neuromuscular blockade. It is necessary to investigate possibility of application of more specific and more accurate method in TOF monitoring, such as quantitative TOF method. Determination of difference between the values of T1 and T4 muscle contraction, obtained by quantitative TOF method, may indicate the presence of neuromuscular blockade on tested muscle. In addition to this, by application of quantitative TOF method, it is necessary to determine is there a difference in period of recovery from neuromuscular blockade between defferent muscles. Comparison of T4/T1 ratios between different muscles may indicate presence of different period of recovery from neuromuscular blockade. Methods: Study analyzed differences between recovery of foot - abductor hallucis muscle and hand - first dorsal interosseous muscle by application of quantitative TOF test on 147 patients undergoing lumbar spine surgery. T1 to T4 decrements on hand and foot TOF were determined and classified into different groups, depending of neuromuscular blocking agents (NMBA) dose and elapsed time after administration. T1 - T4 decrements were compared between hand and foot TOF and differences between muscle recovery were determined. Visual method of TOF test was performed by anesthesiologists, by using peripheral nerve stimulator and stimulating ulnar nerve. Quantitative TOF test was measured on first dorsal interosseous muscle, and compared with visual TOF results obtained on adductor pollicis muscle. Results: There are significant differences between T1 - T4 decrements obtained on tested muscles of hand and foot (p&lt;0.05). T1-T4 decrement determined on abductor hallucis muscle had lower values, respectively more rapid recovery, than first dorsal interosseous muscle (p&lt;0.05). Quantitative method of TOF test had reliable and correct results in all tested subjects, while visual interpretation of TOF method showed accurate results in 40 % of all cases. Results indicated that significant difference was present between quantitative and visual method of TOF interpretation. Conclusions: Difference between observed recovery of hand and foot muscles is indicating that quantitative TOF test should be performed on specific site for which accurate data about the level of neuromuscular blockade is needed. During lumbar spine surgery, in addition to hand TOF, foot TOF should be included as it provides more accurate data needed for neurophysiological intraoperative monitoring. Quantitative TOF method provides more accurate data about level of neuromuscular blockade if compared with subjective visual TOF method.</p>

Background. Diabetes requires significant disease management, patient-provider communication, and interaction between patients, family members, caregivers, and care teams. Emerging patient-facing technologies, such as cellular-enabled glucose meters, can facilitate additional care support and improve diabetes self-management. This study evaluated patient acceptability, feasibility, and efficacy of a diabetes care support program facilitated by cellular-enabled glucose meters. Methods. A two-phase study approach was taken. Get In Touch – Phase 1 (GIT-1) was a 1-month pilot involving patients with type 1 and type 2 diabetes. Get In Touch – Phase 2 (GIT-2) was a 12-month randomized controlled crossover trial involving patients with poorly-controlled type 2 diabetes. Results from GIT-1 and preliminary results from GIT-2 are presented. Results. GIT-1 participants with type 1 (n=6) and type 2 (n=10) diabetes reported the intervention and cellular-enabled glucose meter were easy to use and useful while identifying potential areas of improvement. GIT-2 participants in both the intervention (n=60) and control (n=60) groups saw significant improvements in treatment satisfaction and A1c change, with intervention participants experiencing slightly greater improvements in each after 6 months (p=0.09 and p=0.16, respectively) compared to control participants. Conclusions. Patients reported favorable acceptability of the intervention. Preliminary results from a randomized trial demonstrated potential of intervention to improve patient-reported and physiological health outcomes. Future studies should evaluate feasibility and efficacy over a longer period of time, with a greater number of participants, and targeting different populations of patients with diabetes. Provider perspectives and changes in provider behavior, clinical work flow, and caregiver burden should also be assessed.