Acidose metabólica é um fenômeno comum e clinicamente significativo em pacientes com sepse grave ou choque séptico. Entretanto, sua composição não é bem estabelecida. Neste estudo, descrevemos a composição da acidose metabólica em pacientes com sepse grave ou choque séptico desde sua internação em unidade de terapia intensiva (UTI) até os quinto dia de internação em unidade de terapia intensiva (UTI). Na admissão à UTI, a acidose metabólica foi um fenômeno muito freqüente. Ela era composta principalmente pelo componente derivado dos íons inorgânicos (dado principalmente pela diferença sódio cloro), seguido em magnitude pelo componentes decorrentes de ânions não mensuráveis e lactato e atenuada por hipoalbuminemia. A magnitude da acidose metabólica e hipercloremia foram maiores entre os pacientes não-sobreviventes (considerando a mortalidade hospitalar). Em análise multivariada o grau de acidose por íons inorgânicos, além do escore de gravidade APACHE II e nível inicial de creatinina sérica, esteve associada a mortalidade hospitalar. Ao longo do período de estudo, os pacientes sobreviventes apresentaram melhora da acidose metabólica por diminuição dos níveis de ânions não-mensuráveis e lactato. Os não sobreviventes mantiveram a mesma magnitude de acidose metabólica e apresentaram queda do pH por aumento da PCO2 / Metabolic acidosis is frequently found in patients with severe sepsis and septic shock. Several studies have shown that the amount of metabolic acidosis measured by the standard base excess (SBE) at hospital admission and its evolution throughout the first days of intensive care unit (ICU) stay are correlated with clinical outcome. However, the precise composition of the metabolic acidosis in patients with severe sepsis and septic shock is not well known. In this study, we have described the composition of metabolic acidosis in patients with severe sepsis or septic shock at ICU admission and throughout the first five days of ICU stay, by applying the quantitative physicochemical methodology. Metabolic acidosis was extremely frequent at admission to the ICU. Its main component was attributable to the inorganic ion difference disturbance (mainly determined by the Na Cl difference), followed in magnitude by unmeasured anions and lactate´s components. Hypoalbuminemia represented the most frequent and important alkalinizing component. The degree of metabolic acidosis and hyperchloremia was more pronounced in the non-survivors group (according to hospital mortality). In a multivariate analysis the degree of metabolic acidosis due to disturbances in innorganic ion difference was associated to hospital mortality. Acidosis in survivors was corrected during the study period due to a decrease in lactate and SIG levels, whereas non-survivors did not correct their metabolic acidosis and suffered a decrease in the pH due to an increase in PCO2 levels

Objectives: Negative energy balance can impair regeneration of the respiratory epithelium and limit the functionality of respiratory muscles, which can prolong mechanical ventilation. The present study sought to quantify and identify deviation in energy requirements of patients with septic shock during and upon liberation from mechanical ventilation. Methods: Patients admitted into intensive care with initial diagnosis of septic shock and mechanical ventilation-dependent were recruited. Their metabolic requirements before and after liberation from mechanical ventilation were measured by indirect calorimetry. Paired t-test was used to examine the variance between the two modes of breathing and Spearman rho correlation coefficient to examine relationship of selected indicators. Results: Thirty-five patients, 20 males and 15 females mean age 69 ±10 years, body height of 1.58 ±0.08 meters, and ideal body weight 59.01 ±7.63 kg were recruited. Median APACHEII score was 22, length of stay in the intensive care was 45 ±65 days and duration on mechanical ventilation was 24 ±25 days. Measured energy expenditure during ventilation was 2090 ±489 kcal∙d-1 upon liberation from ventilation was 1910 ±579 kcal∙d-1, and actual caloric intake was 1148 ±495 kcal∙d-1. Paired-t test showed that measured energy expenditure (p=0.02), actual calories provision and energy expenditure with (p=0.00) and without (p=0.00) ventilator support were all significantly different. Mean carbohydrate oxidation was 0.17 ±0.09 g·min-1 when patients were on mechanical ventilation compared to 0.14 ±0.08 g·min-1 upon liberalization from it, however, the results were not statistically significant. Furthermore, mean lipid oxidation was 0.08 ±0.05 g·min-1 during mechanical ventilation and 0.09±0.07 g·min-1 upon liberalization from it and the mean difference was not statistically significant. Spearman correlation coefficient showed a positive relationship between actual calorie provision and duration of stay in intensive care (r=0.41 and p=0.01) and duration on mechanical ventilation (r=0.55 and p=0.00). Oxygen consumption (r=0.49 and p=0.00) and carbon dioxide production (r=0.4 and p=0.02) were moderately strong and positive during and upon liberation from mechanical ventilation. Correlation between lipid oxidation and oxygen consumption during ventilation (r=0.74, p=0.00) and after ventilation (r=0.82, p=0.00) as well as lipid oxidation and carbon dioxide production during ventilation (r=0.37, p=0.03) and liberation from ventilator (r=0.91, p=0.00) were significantly correlated with each other in grams per minute only. Conclusions: This is a pioneering study to examine energy expenditure and substrate utilization and oxidation within a single cohort of patients. The lower measured energy expenditure upon liberation from mechanical ventilation among critically ill patients could result from positive pressure support from ventilation, the repeated cycle of “rest” and “work” during weaning from ventilators and the asynchronization between self-initiated breathing effort and the ventilatory support. The positive relationship in duration on mechanical ventilation and length of stay with calorie consumption could be longer stay led to more time for progression to reach nutrition targets. . Any discrepancy in energy expenditure and substrate utilization with and without ventilatory support should be monitored. Future studies are important to examine whether matching energy expenditure with energy intake could promote positive clinical outcomes.

Orientador: Daniela Ponce / Resumo: A vancomicina é um antiobiótico chave no tratamento de infecções graves por germes gram positivos multirresistentes e deve ser administrada com segurança, buscando minimizar o risco de nefrotoxicidade e garantir a sua eficácia. Entretanto, são escassos os estudos que avaliaram a monitorização de seu nível plasmático e sua associação com desfechos clínicos, como desenvolvimento de lesão renal aguda (LRA) e óbito. OBJETIVO: Ao avaliar pacientes com sepse em uso de vancomicina admitidos em unidade de terapia intensiva (UTI), os objetivos deste estudo foram avaliar a prevalência de vancocinemia em níveis adequados, subterapêuticos e tóxicos e o impacto da adequação dos níveis séricos de vancomicina sobre a LRA e mortalidade precoce. METODOLOGIA: Estudo prospectivo observacional do tipo coorte de pacientes em uso de vancomicina admitidos em duas UTIs do Hospital das Clínicas da Faculdade de Medicina de Botucatu de 01 de agosto de 2016 a 31 de julho de 2017 de modo diário e ininterrupto. RESULTADOS: Foram avaliados 189 pacientes, dos quais foram incluídos 63. Os principais motivos de admissão na UTI foram afecções pulmonares (52,4%) e pós-operatório (15,9%). LRA foi diagnosticada em 44,4% dos pacientes, sendo que a maioria foi classificada como LRA KDIGO III (46,4%). Os pacientes que desenvolveram LRA apresentaram, comparativamente àqueles sem LRA, maiores valores de creatinina basal, maior uso de diurético e de droga vasoativa e maior porcentagem de nível sérico tóxico. A regressã... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Vancomycin is a key antiobiotic in the treatment of severe infections caused by multiresistant gram-positive germs and should be administered safely in order to minimize the risk for nephrotoxicity and ensure its efficacy. However, there are few studies evaluating the monitoring of its plasma level and its association with clinical outcomes, such as the development of acute kidney injury (AKI) and death. OBJECTIVE: The aim of this study was to evaluate the prevalence of vancocinemia at appropriate levels, subtherapeutic and toxic levels, and the impact of the adequacy of vancomycin levels on the AKI and early mortality. METHODS: Prospective observational cohort study of vancomycin patients admitted to two intensive care units of the Clinical Hospital of Botucatu Medical School from August 1, 2016 to July 31, 2017 in a daily and uninterrupted manner. RESULTS: A total of 189 patients were evaluated and 63 were included. The main reasons for admission to the ICU were pulmonary (52.4%) and postoperative (15.9%) conditions. AKI was diagnosed in 44.4% of the patients, most of them were classified as AKI KDIGO III (46.4%). Patients who developed AKI showed higher values of baseline creatinine, greater use of diuretics and vasoactive drugs, and a higher percentage of toxic serum levels compared to those without AKI. Logistic regression showed that the highest level of vancocinemia between the 2nd and 4th days was predictor of AKI, preceding its diagnosis in at least 48 hours (OR= 1,1... (Complete abstract click electronic access below) / Mestre

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Ao longo dos últimos anos, apesar de todo desenvolvimento e pesquisa, a mortalidade na sepse permanece elevada. Na área de microcirculação foram realizados estudos em modelos experimentais de sepse ao longo das últimas duas décadas, quando se observou, através de técnicas invasivas, alterações como redução expressiva da densidade capilar funcional. A técnica denominada sidestream dark field (SDF) imaging, recentemente desenvolvida, permite a avaliação da microcirculação de forma transcutânea. A utilização desta técnica permitiu evidenciar a redução da densidade capilar funcional em pacientes com sepse grave quando comparado a um indivíduo saudável. Posteriormente, foi demonstrado que alterações persistentes na microcirculação de pacientes sépticos, mesmo com sinais vitais estabilizados, estão associadas com pior prognóstico.Evidentemente, os pacientes com sepse grave ou choque séptico sofrem uma grande quantidade de intervenções terapêuticas, aonde muitas delas alteram a microcirculação. Estudos analisando a microcirculação em pacientes em uso de nitroglicerina, corticóide, recebendo hemotransfusão ou ainda infusão de noradrenalina foram publicados recentemente.Entretanto, até o presente momento, não existem publicações que descrevam a influência dos sedativos na microcirculação de pacientes com choque séptico. As drogas mais comumente utilizadas para sedação de pacientes em ventilação mecânica são o sedativo midazolam e o anestésico propofol. Os objetivos do estudo foram: avaliar o efeito dos principais agentes sedativos utilizados na prática clínica na microcirculação de pacientes com choque séptico utilizando a técnica de sidestream dark field imaging, comparar os efeitos na microcirculação do midazolam com o propofol em pacientes com choque séptico e verificar se existe relação das alterações microcirculatórias provocadas pelos sedativos com as variações de diferentes parâmetros hemodinâmicos, gasométricos ou metabólicos como pressão arterial, índice cardíaco, lactato e saturação venosa central de oxigênio. Foram estudados (estudo prospectivo) 16 pacientes internados no Centro de Terapia Intensiva da Casa de Saúde São José. Os pacientes internados com diagnóstico de choque séptico e que possuíam indicação clínica de ventilação mecânica e de suspensão diária da sedação foram submetidos ao estudo da microcirculação na mucosa sublingual utilizando a técnica de sidestream dark field imaging. Estes pacientes foram sedados conforme orientação do protocolo já existente de sedação, inicialmente com propofol e posteriormente com midazolam. Os principais resultados observados foram:a macrohemodinâmica não diferiu nos 2 momentos do exame, o BIS (bispectral índex of sedation) se manteve na faixa recomendada nos 2 momentos do exame, tendo aumentado quando o paciente acordava, conforme esperado, e a proporção de vasos pequenos perfundidos e o índice de fluxo da microcirculação foram significativamente menores, enquanto o índice de heterogeneidade foi significativamente maior quando os pacientes estavam recebendo infusão de propofol quando comparados com a infusão de midazolam. Concluímos que, em pacientes com choque séptico, a administração de midazolam resulta em uma melhora dos parâmetros microcirculatórios quando comparada com a administração de propofol. Essa diferença não pode ser atribuída a alterações de variáveis hemodinâmicas sistêmicas. / Over the past few years, despite all research and development, mortality from sepsis remains high. In microcirculatory studies using experimental models of sepsis, and invasive techniques, significant reduction in functional capillary density were observed. The recently developed technique called sidestream dark field (SDF) imaging, allows transcutaneously evaluation of the microcirculation. This technique has demonstrated reduction on functional capillary density in patients with severe sepsis, when compared to healthy individuals. Subsequently, it was shown that even in septic patients with stabilized vital signs, persistent alterations in the microcirculation are associated with worse prognosis. Obviously, patients with severe sepsis or septic shock suffer a lot of therapeutic interventions, many of them affecting the microvasculature. Studies analyzing the microcirculation in patients using nitroglycerin, corticosteroids, receiving blood transfusion or infusion of norepinephrine were recently published. However, to date, no publications have described the influence of sedatives in the microcirculation of these patients. The most commonly drugs used for sedation of mechanically ventilated patients are midazolam and propofol. The main objectives of this study were to observe the effects of two sedative agents used in clinical practice in the microcirculation of patients with septic shock. The sidestream dark field imaging technique was used to compare the effects on microcirculation of midazolam with propofol in patients with septic shock and verify a relationship between microcirculatory changes caused by sedatives and different variations of hemodynamic parameters such as blood pressure, heart rate, lactate and central venous oxygen saturation.We have prospectively studied 16 patients admitted to the Intensive Care Unit of Casa de Saúde São José. Patients admitted with a diagnosis of septic shock and in need of mechanical ventilation were submitted to microcirculation analysis in the sublingual mucosa using sidestream dark field imaging technique. These patients were sedated according to the sedation protocol, initially with propofol, and later on with midazolam. The main results were: the macrohemodynamics did not differ during the two moments of examination; BIS (bispectral index of sedation) remained in the range recommended during both exams and increased when patients woke up, as expected, and finally, the proportion of small vessels perfused and microcirculatory flow index were significantly lower, while the heterogeneity index was higher, when patients were receiving propofol infusion in comparison with the midazolam one. We concluded that in patients with septic shock, midazolam administration results in an improvement of the microcirculation when compared with the administration of propofol and this difference could not be attributed to changes in systemic hemodynamic.

La réponse immuno-inflammatoire au cours du choc septique associe une importante réponse inflammatoire initiale responsable de l'état de choc et le développement secondaire d'altérations du système immunitaire. Les polynucléaires neutrophiles (PNN) jouent un rôle central dans la réponse immunitaire. Des données récentes de la littérature décrivent également un rôle immunosuppresseur jusqu'alors méconnu pour ces cellules. Nous avons exploré leur possible implication dans la physiopathologie du choc septique.Le but de ce travail était l'exploration des altérations phénotypiques, fonctionnelles et transcriptomiques des PNN lors de la phase immunosuppressive du choc septique. Nos résultats montrent une diminution de la capacité de migration des PNN ainsi qu'une diminution de la production de composés bactéricides (myéloperoxydase, lactoferrine) alors que la réponse aux cytokines et la phagocytose n'apparaissent pas altérées. Le contenu en myéloperoxydase et la présence de PNN immatures CD10dimCD16dim étaient indépendamment associés à une mortalité plus élevée. De manière intéressante, CD177 était le gène le plus différentiellement exprimé entre les patients et les volontaires sains. CD177 et CD10 étaient inversement corrélés. Ainsi, la diminution du chimiotactisme, la perte de myéloperoxydase, la présence de cellules immatures et leurs liens avec la mortalité pourraient contribuer au contexte d'immunosuppression présent chez les patients septiques. Au final, les pistes d'exploration futures convergent vers la population de PNN immatures et le rôle spécifique du CD177 dans les états septiques sévères / Severe septic syndromes deeply impair innate and adaptive immunity and are responsible for sepsis-induced immunosuppression. While neutrophils represent the first line of defense against infection, little is known about their phenotype and functions few days after sepsis, when the immunosuppressive phase is maximal (i.e., between day 3 and 8). The objective of this study was thus to perform a global evaluation of neutrophil alterations in immunosuppressed septic patients based on phenotypic, functional and transcriptomic studies. Our results highlight a markedly altered neutrophil chemotaxis (functional and chemokine receptor expressions), oxidative burst, lactoferrin content and an increased number of circulating immature granulocytes (i.e., CD10dimCD16dim). In contrast, phagocytosis and activation capacities were conserved. It is interesting to note that a diminished myeloperoxidase expression appeared as the best predictor to identify a group of septic shock patients at high risk of death. Similarly, patients with lower proportions of CD10dimCD16dim granulocytes had a significant better survival compared with patients presenting a higher percentage. CD177 mRNA, coding for an activation molecule in chemotaxis but also known to be overexpressed in immature cells, had the highest fold change modulation between patients and controls. Considering the potential dual roles of CD177 neutrophil (i.e., maturation / chemotaxis), its participation in septic shock pathophysiology deserves further investigation. To conclude, circulating neutrophils present with phenotypic, functional and morphological alterations few days after sepsis onset. These dysfunctions may participate in the deleterious role of sepsis-induced immunosuppression. The present results open new perspectives in the mechanisms favoring nosocomial infections after septic shock. They deserve to be further investigated in a larger clinical study and in animal models recapitulating these alterations

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / O uso agrÃcola do lodo de esgoto à uma alternativa que apresenta vantagens ambientais quando comparada a outras prÃticas de destinaÃÃo final e a sua aplicaÃÃo no solo pode trazer benefÃcios à agricultura. O presente estudo teve como objetivo avaliar a toxicidade aguda de resÃduos de caminhÃes limpa-fossa (lodo sÃptico), de diferentes residÃncias atravÃs da utilizaÃÃo de bioensaios, com trÃs organismos bioindicadores de toxicidade, os microcrustÃceos (Daphnia magna e Daphnia similis) e bactÃrias (Vibrio fischeri) no Sistema MicrotoxÂ. Primeiramente foi feita a caracterizaÃÃo fÃsico-quÃmica, microbiolÃgica e metais pesados dos resÃduos esgotados dos caminhÃes limpa-fossa e posteriormente foram realizados testes de toxicidade. As coletas foram realizadas quinzenalmente na ETE SÃo CristÃvÃo/CAGECE, em Fortaleza-CE, onde as amostras foram levadas ao laboratÃrio para realizar as anÃlises de pH, temperatura, alcalinidade, condutividade elÃtrica, sÃrie de sÃlidos, DBO, DQO, sÃrie de nitrogÃnio, fÃsforo e coliformes termotolerantes. Observou-se que estes resÃduos apresentaram concentraÃÃes bem mais elevadas que as de esgoto domÃstico e tambÃm com caracterÃsticas bastante variÃveis. A fraÃÃo volÃtil representa cerca de 65% dos sÃlidos totais e a relaÃÃo SV/ST foi de 0,6 indicando uma possÃvel estabilidade de acordo com a CONAMA 375/2006. TambÃm foram realizadas anÃlises de metais pesados (CÃdmio, Cromo, ManganÃs, NÃquel, Zinco, Chumbo, Ferro e Cobre) para verificar se tinha alguma correlaÃÃo com a toxicidade. Todas as amostras esgotadas de caminhÃes limpa-fossa apresentaram toxicidade aguda para os trÃs microorganismos Daphnia magna, Daphnia similis e Vibrio fischeri com mÃdia de CE50 igual à 54%, 41% 52% respectivamente, sendo todos considerados tÃxicos. Com relaÃÃo à sensibilidade a Daphnia similis foi o organismo que apresentou maior sensibilidade para resÃduos sÃpticos, pois quanto menor o CE50 mais tÃxica à a amostra. Pelos resultados obtidos, os resÃduos de caminhÃes limpa-fossa apresentaram toxicidade e nÃo poderiam ser utilizados na agricultura sem um prÃvio tratamento para a remoÃÃo da toxicidade. / O uso agrÃcola do lodo de esgoto à uma alternativa que apresenta vantagens ambientais quando comparada a outras prÃticas de destinaÃÃo final e a sua aplicaÃÃo no solo pode trazer benefÃcios à agricultura. O presente estudo teve como objetivo avaliar a toxicidade aguda de resÃduos de caminhÃes limpa-fossa (lodo sÃptico), de diferentes residÃncias atravÃs da utilizaÃÃo de bioensaios, com trÃs organismos bioindicadores de toxicidade, os microcrustÃceos (Daphnia magna e Daphnia similis) e bactÃrias (Vibrio fischeri) no Sistema MicrotoxÂ. Primeiramente foi feita a caracterizaÃÃo fÃsico-quÃmica, microbiolÃgica e metais pesados dos resÃduos esgotados dos caminhÃes limpa-fossa e posteriormente foram realizados testes de toxicidade. As coletas foram realizadas quinzenalmente na ETE SÃo CristÃvÃo/CAGECE, em Fortaleza-CE, onde as amostras foram levadas ao laboratÃrio para realizar as anÃlises de pH, temperatura, alcalinidade, condutividade elÃtrica, sÃrie de sÃlidos, DBO, DQO, sÃrie de nitrogÃnio, fÃsforo e coliformes termotolerantes. Observou-se que estes resÃduos apresentaram concentraÃÃes bem mais elevadas que as de esgoto domÃstico e tambÃm com caracterÃsticas bastante variÃveis. A fraÃÃo volÃtil representa cerca de 65% dos sÃlidos totais e a relaÃÃo SV/ST foi de 0,6 indicando uma possÃvel estabilidade de acordo com a CONAMA 375/2006. TambÃm foram realizadas anÃlises de metais pesados (CÃdmio, Cromo, ManganÃs, NÃquel, Zinco, Chumbo, Ferro e Cobre) para verificar se tinha alguma correlaÃÃo com a toxicidade. Todas as amostras esgotadas de caminhÃes limpa-fossa apresentaram toxicidade aguda para os trÃs microorganismos Daphnia magna, Daphnia similis e Vibrio fischeri com mÃdia de CE50 igual à 54%, 41% 52% respectivamente, sendo todos considerados tÃxicos. Com relaÃÃo à sensibilidade a Daphnia similis foi o organismo que apresentou maior sensibilidade para resÃduos sÃpticos, pois quanto menor o CE50 mais tÃxica à a amostra. Pelos resultados obtidos, os resÃduos de caminhÃes limpa-fossa apresentaram toxicidade e nÃo poderiam ser utilizados na agricultura sem um prÃvio tratamento para a remoÃÃo da toxicidade. / A way to recycle the nutrients and organic matter from sewage sludge from septic tanks and cesspools would return those elements to biogeochemical cycles. The agricultural use of sewage sludge is an alternative that provides environmental benefits when compared to other final disposal practices and its application in soil can bring benefits to agriculture. The present study aimed to evaluate the acute toxicity of clean trucks (septic sludge) from different homes through the use of bioassays, with three bodies bioindicators of toxicity, the microcrustaceans (Daphnia magna and Daphnia similis) and bacteria (Vibrio fischeri) in the Microtox  System. First was made the physico-chemical, microbiological characterization and heavy metals waste exhausted clean trucks and trench-toxicity tests were carried out at a later date. The collections were held fortnightly in the ETE SÃo CristÃvÃo, where samples were brought to the laboratory to perform the analyses of pH, alkalinity, temperature, electrical conductivity, solids, BOD, COD, nitrogen, phosphorus and termotolerantes coliforms. It was noted that such waste presented well concentrations higher than those of domestic sewage and also features plenty of variables. The volatile fraction accounts for around 65% of total solids and SV/ST was 0.6, indicating that the septic tanks and septic sludge can be considered stable according to the CONAMA 375/2006. Were also conducted analyses of heavy metals (Cadmium, chromium, manganese, nickel, zinc, lead, iron and copper) to verify that had some correlation with toxicity. All samples clean truck depleted-fossa showed acute toxicity for microorganism three Daphnia magna, Daphnia similis, and Vibrio fischeri averaging equal to 54%, EC50 41% 52% respectively, all of which are considered toxic. With respect to sensitivity to Daphnia similis was the body that has greater sensitivity to septic waste, because the lower the EC50 is more toxic to sample. By the results obtained, the clean trucks waste-fossa are toxic and could not be used in agriculture without a prior treatment for the removal of toxicity / A way to recycle the nutrients and organic matter from sewage sludge from septic tanks and cesspools would return those elements to biogeochemical cycles. The agricultural use of sewage sludge is an alternative that provides environmental benefits when compared to other final disposal practices and its application in soil can bring benefits to agriculture. The present study aimed to evaluate the acute toxicity of clean trucks (septic sludge) from different homes through the use of bioassays, with three bodies bioindicators of toxicity, the microcrustaceans (Daphnia magna and Daphnia similis) and bacteria (Vibrio fischeri) in the Microtox  System. First was made the physico-chemical, microbiological characterization and heavy metals waste exhausted clean trucks and trench-toxicity tests were carried out at a later date. The collections were held fortnightly in the ETE SÃo CristÃvÃo, where samples were brought to the laboratory to perform the analyses of pH, alkalinity, temperature, electrical conductivity, solids, BOD, COD, nitrogen, phosphorus and termotolerantes coliforms. It was noted that such waste presented well concentrations higher than those of domestic sewage and also features plenty of variables. The volatile fraction accounts for around 65% of total solids and SV/ST was 0.6, indicating that the septic tanks and septic sludge can be considered stable according to the CONAMA 375/2006. Were also conducted analyses of heavy metals (Cadmium, chromium, manganese, nickel, zinc, lead, iron and copper) to verify that had some correlation with toxicity. All samples clean truck depleted-fossa showed acute toxicity for microorganism three Daphnia magna, Daphnia similis, and Vibrio fischeri averaging equal to 54%, EC50 41% 52% respectively, all of which are considered toxic. With respect to sensitivity to Daphnia similis was the body that has greater sensitivity to septic waste, because the lower the EC50 is more toxic to sample. By the results obtained, the clean trucks waste-fossa are toxic and could not be used in agriculture without a prior treatment for the removal of toxicity

O Brasil apresenta um déficit relevante de saneamento em áreas rurais. Segundo dados do último censo brasileiro, de 2010, cerca de 29,9 milhões de pessoas residem em áreas rurais, totalizando aproximadamente 8,1 milhões de domicílios. Como os domicílios rurais costumam ser dispersos, e mesmo nas áreas mais concentradas não há rede coletora de esgotos, as famílias geralmente recorrem a soluções alternativas para o esgotamento sanitário, muitas vezes inadequadas, como o uso de fossas rudimentares, em 49,9 por cento de domicílios rurais, e outras formas em 7,4 por cento de domicílios rurais, totalizando 57 por cento de domicílios rurais. Algumas alternativas para o tratamento de esgoto vêm sendo implantadas em áreas rurais, por meio de tecnologias sociais. Entre elas, podem-se destacar as fossas sépticas biodigestoras, que foram desenvolvidas pela Empresa Brasileira de Pesquisa Agropecuária - EMBRAPA. Tais tecnologias têm sido implementadas em algumas comunidades rurais brasileiras destacando-se o caso das comunidades rurais dos bairros dos Afonsos e do Cantagalo, pertencentes ao município de Pouso Alegre, estado de Minas Gerais, Brasil. Esta pesquisa tem o objetivo de analisar como ocorre o processo de implantação das fossas biodigestores nesses bairros e verificar se elas, de fato, cumprem com o papel de facilitadoras para o tratamento de esgoto em área rural do município de Pouso Alegre MG. Para isso foi realizada pesquisa de caráter qualitativo, por meio de levantamento documental e bibliográfico, entrevistas semiestruturadas, análise das transcrições e categorização dos dados. Para categorização e análise dos dados foi utilizada bibliografia sobre Tecnologia Social (TS). Apesar de os resultados evidenciarem pouca participação dos moradores no processo de tomada de decisão sobre o uso da tecnologia, há grande influência e credibilidade nas propostas feitas por uma organização não governamental local, favorecendo as intervenções atuais o que também possibilitará a inserção da TS como política pública, se aprovado o Plano Municipal de Saneamento Básico / Brazil has a significant sanitation deficit in rural areas. According to data from the last Brazilian census, 2010, about 29.9 million people live in rural areas, totaling approximately 8.1 million households. As rural households are often dispersed, and even in the most concentrated areas there is no sewerage network, households often resort to alternative solutions to sanitary sewage, often inadequate, such as the use of rudimentary septic tanks, at 49.9 per cent of Rural households, and other forms in 7.4 per cent of rural households, totaling 57 per cent of rural households. Some alternatives for the treatment of sewage are seen being implanted in rural areas, through social technologies. Among them, we can highlight the septic tanks biodigestoras, which were developed by EMBRAPA. Such technologies have been implemented in some Brazilian rural communities, highlighting the case of the rural communities of Afonsos and Cantagalo, belonging to the municipality of Pouso Alegre - MG. This research has the objective of analyzing how the process of implantation of the biodigestors in these districts occurs and verify if they, in fact, fulfill the role of facilitators for the treatment of sewage in rural area of the municipality of Pouso Alegre - MG. For this purpose, qualitative research was carried out, through documentary and bibliographic surveys, semi-structured interviews, transcription analysis and data categorization. For data categorization and analysis, a bibliography on Social Technology (TS) was used. Although the results show little participation of the residents in the decision making process on the use of technology, there is great influence and credibility in the proposals made by the local NGO, favoring the current interventions, which also allowed the inclusion of the TS as a public policy, if approved The Municipal Sanitation Basic Plan

Submitted by Erika Demachki (erikademachki@gmail.com) on 2014-08-26T18:27:33Z No. of bitstreams: 2 license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Tratamento dos resíduos de fossas e tanques sépticos em um sistema de alagado construído.pdf: 3758497 bytes, checksum: 51e75f00b9f942fa3c8bcb520f75bbea (MD5) / Made available in DSpace on 2014-08-26T18:27:33Z (GMT). No. of bitstreams: 2 license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Tratamento dos resíduos de fossas e tanques sépticos em um sistema de alagado construído.pdf: 3758497 bytes, checksum: 51e75f00b9f942fa3c8bcb520f75bbea (MD5) Previous issue date: 2014-03-31 / Due to the lack of public sewer service in the country, Individual and Household Sewage Disposal Treatment Systems (SITDE) are still widely used in Brazil. The SITDE require cleaning maintenance and at the time of execution of this cleaning occurs the generation of the called Pit and Septic Tanks Waste (RFTS). This material has high load of pollutants and presence of pathogenic organisms and must be properly designed to ensure the quality of the environment and safeguard public health. In this context, low cost and potential for deployment in small settlements technologies emerge as an alternative of treatment. This study aimed to evaluate the efficiency of the Constructed Wetlands System (SAC) with the Vetiver plant species (Chrysopogon zizanioides) in the treatment of the liquid fraction of the RFTS. An experimental system was built with the deployment of two identical tanks. One tank received the vegetation and the other operated as a control treatment. The tanks were filled with a substrate consisting of gravel # 0, gravel # 1 and medium sand. The constructed wetland system (SAC) acted under a descending vertical subsurface flow and RFTS was applied on the system under batch, remaining in the tanks for a period of six (6) days. The RFTS influent to the treatment system was characterized according to the parameters of pH, total oil and grease, ammonia nitrogen, settleable solids, total coliforms, Escherichia coli, surface, solid fixed solids, volatile solids, Biochemical Oxygen Demand (BOD) and total phosphorus. The RFTS treated by SAC was analyzed according to the same parameters and the results were compared with the stipulations for disposition in water bodies of class 2, according to Resolution 430/2011 of Conama and Goiás State Decree 1.745/1979. The attributes removal efficiency was calculated considering the phenomenon of evapotranspiration, which showed an average rate of 38.11% in the SAC. The tributary RFTS system showed a great variability in the concentrations of the attributes. The results were subjected to F test (5% probability). Statistically, the only differed treatments between the tank vegetated and the tank control was removal of BOD which was more effective WS with the average removal of 86.80 %, while the tank control showed an average increase of 65.94 %. The average concentrations output WS met the requirements under federal and state law , except for E. coli showed an average outlet concentration can change the class of the receptor. Statistically, the treatments (vegetated tank and control tank) differed only for the BOD removal, which was more effective for the SAC, with the average removal of 86.80%, while the tank control showed an average increase of 65.94%. The average concentrations of SAC output attended the provided by the federal and state laws or release in Class 2 water. / Devido à carência do serviço público de esgotamento sanitário no país, os Sistemas Individuais de Tratamento e Disposição de Esgoto Doméstico (SITDE) ainda são muito utilizados. Os SITDE necessitam de manutenção com realização de limpeza e, no momento da execução desta limpeza ocorre a geração do chamado Resíduo de Fossas e Tanques Sépticos (RFTS). Este material possui elevada carga de poluentes e presença de organismos patogênicos devendo ser destinado corretamente de forma a garantir a qualidade do meio ambiente e preservar a saúde pública. Neste contexto, tecnologias de baixo custo e com potencial para implantação em pequenos núcleos populacionais surgem como uma alternativa de tratamento. Este trabalho objetivou avaliar a eficiência do Sistema de Alagado Construído (SAC) com a espécie vegetal capim Vetiver (Chrysopogon zizanioides) no tratamento da fração líquida dos RFTS. Foi construído um sistema experimental com a implantação de dois tanques idênticos. Um tanque recebeu a vegetação e o outro operou como controle (testemunha). Os tanques foram preenchidos com substrato formado por brita #0, brita #1 e areia média. O sistema de alagado construído (SAC) atuou em regime de fluxo vertical subsuperficial descendente e o RFTS foi aplicado no sistema em regime de batelada permanecendo nos tanques por um período de 6 (seis) dias. O RFTS afluente ao sistema de tratamento foi caracterizado segundo os parâmetros pH, óleos e graxas totais, nitrogênio amoniacal, sólidos sedimentáveis, coliformes totais, Escherichia coli, sólidos totais, sólidos fixos, sólidos voláteis, Demanda Bioquímica de Oxigênio (DBO) e fósforo total. O RFTS tratado pelo SAC foi analisado conforme os mesmos parâmetros e os resultados foram comparados com o estipulado para a disposição em corpos hídricos de classe 2, conforme a Resolução 430/2011 do Conama e o Decreto estadual 1.745/1979, do Estado de Goiás. A eficiência na remoção dos atributos foi calculada considerando o fenômeno da evapotranspiração, que apresentou taxa média de 38,11% no SAC. O RFTS afluente ao sistema experimental apresentou grande variabilidade nas concentrações dos atributos. Os resultados foram submetidos ao teste F (5% de probabilidade). Estatisticamente os tratamentos (tanque vegetado e tanque controle) diferiram apenas para a remoção da DBO onde o SAC foi mais eficaz com a remoção média de 86,80%, enquanto o tanque controle apresentou incremento médio de 65,94%. As concentrações médias de saída do SAC atenderam ao disposto pelas legislações federal e estadual para lançamento em corpos hídricos de classe 2.

A sepse é caracterizada por uma produção excessiva de mediadores inflamatórios, acompanhada de taquicardia e hipotensão. Experimentalmente, a administração de endotoxina (Lipopolissacarídeo, LPS) em doses relativamente elevadas induz choque endotoxêmico, sendo um bom modelo de estudo da sepse. Diversos grupos têm demonstrado ações antiinflamatórias e antitumorais do citral, um composto do óleo essencial de Cymbopogon citratus. Nosso laboratório demonstrou ação antipirética do citral em modelo de febre induzida por LPS, acompanhada de redução nos níveis de citocinas plasmáticas e de prostaglandina E2 (PGE2) no plasma e área pré óptica do hipotálamo (POA), importante região termorregulatória. A hipótese testada neste trabalho foi a de que o citral atenua a hipotensão provocada pela endotoxina, além de amenizar as alterações termoregulatórias. Todos os procedimentos foram executados de acordo com os princípios éticos de experimentação animal, aprovados pelo comitê de ética local (CEUA 2015.1 1214 58-2). Foi realizado o implante de cânulas na artéria e veia femoral para registro da pressão arterial e administração de LPS (1,5 mg/kg) ou salina apirogênica 0,9% além do implante de datalogger na cavidade peritoneal de ratos Wistar, para registro da temperatura corporal. No dia do registro, 30 minutos antes da administração de LPS ou salina, os animais receberam citral (100 mg/kg) ou tween 80 a 1% (veículo) por via oral. Os parâmetros cardiovasculares e temperatura corporal foram registrados por 300 minutos após os respectivos tratamentos. Os valores de pressão arterial média (PAM) e frequência cardíaca (FC) foram coletados a cada 10 minutos após o tratamento e a temperatura corporal foi registrada pelo datalogger em intervalos de 5 minutos. Em outro protocolo foi realizado apenas o implante de cânula na veia femoral dos animais de todos os grupos para administração de LPS ou salina, coleta de sangue para dosagem de interleucina 6, PGE2, nitrito e nitrato e corticosterona e coleta do encéfalo para dosagem de PGE2 e PGD2. As diferenças estatísticas entre os grupos foram analisadas pelo teste ANOVA two-way seguido por pós teste de Newman-Keuls, com o nível de significância adotado de p < 0,05. A administração de LPS provocou queda na PAM eaumento na FC. Tais respostas não foram afetadas pela administração prévia de citral. O LPS também induziu febre e aumento nas concentrações plasmáticas de interleucina - 6 (IL-6), óxido nítrico (NO), PGE2 e corticosterona. Esses parâmetros não foram alterados pela pré- administração de Citral. No entanto, o citral provocou redução na produção de PGD2 naPOA, sem alterar a de PGE2 nesta região. Podemos concluir que o citral não previne as alterações nos parâmetros cardiovasculares no modelo de endotoxemia em ratos, porém reduz a produção de um mediador termorregulatório e inflamatório do sistema nervoso central (a PGD2), sem alterar a produção de outros mediadores inflamatórios a nível periférico (no plasma). Portanto, em um modelo mais agressivo de inflamação sistênica o citral não se mostrou suficiente para proteger o organismo das ações deletérias do LPS. / Sepsis is characterized by the overproduction of inflammatory mediators, accompanied by tachycardia and hypotension. Experimentally, administration of endotoxin (Lipopolysaccharide, LPS) in relatively high doses induces endotoxemic shock, a widely used model of sepsis in rats. Several groups have demonstrated anti-inflammatory and antitumor roles of citral, an essential oil compound of Cymbopogon citratus. Emilio-Silva et al. (2017) have shown an antipyretic role of citral in a model of LPS-induced fever, accompanied by a reduction of cytokines and prostaglandin E2 plasma levels and in the preoptic area of hypothalamus (POA), the hierarchically most important thermoregulatory region. We hypothesized that citral attenuates the LPS-induced hypotension, besides mitigating the thermoregulatory adjustments in rats. All procedures were performed in agreement with ethical guidelines for animal experimentation aproved by the local ethical committee (CEUA 2015.1 1214 58-2). Femoral artery and vein were implanted with cannulas for blood pressure recording and LPS (1.5 mg/kg) or 0.9% apyrogenic saline injection. In a second surgical procedure a datalogger was implanted into the peritoneal cavity for measurements of body temperature. All surgical procedures were performed under Ketamin/xilazin (100/10 mg/kg) anesthesia. One day after arterial catheterization, 30 minutes prior to LPS or saline administration, the animals received either citral (100 mg / kg) or 1% tween 80 (vehicle) oralstarly. The cardiovascular parameters and body temperature were recorded for 300 minutes after the respective treatments. Mean blood pressure (MAP) and heart rate (HR) were collected every 10 minutes after treatments and body temperature was recorded by the datalogger at 5 minute intervals. Blood samples were obtained in another set of rats for interleukin-6, PGE2, nitrite and nitrate and corticosterone analyses. The brain was removed for PGE2 and PGD2 analyses. Statistical differences between groups were analyzed by the two-way or one-way ANOVA test followed by Newman-Keuls post-test, with significance level adopted at p <0.05. As expected, LPS administration caused a decrease in MAP and an increase in HR, and these responses were not affected by citral. LPS also induced fever and increased plasma levels of interleukin - 6 (IL - 6), nitric oxide (NO), prostaglandin E 2 andcorticosterone. These parameters were also not altered by citral. On the other hand, citral caused a reduction in prostaglandin D2 concentration in the POA, but failed to alter PGE2 levels in this region. Our data are consistent with the notion that citral does not affect changes in cardiovascular and thermoregulatory parameters. Consistently, citral also caused no changes in both LPS-induced peripheral inflammatory mediators (in plasma) and in the POA, except PGD2. Therefore, in our model which mimetic a fairly critical situation, citral may not be sufficient to protect the organism from the deleterious actions of LPS. Financial support: FAPESP / CAPES.

Sepsis is associated with high mortality and morbidity. Immediate recognition and treatment is crucial to prevent complications that can be highly detrimental and cause a significant impact on the U.S. healthcare economy. Numerous studies have been conducted to improve patient outcomes and lower healthcare costs from sepsis and septic shock. Many of these studies were focused on exploring healthcare providers' knowledge and compliance to the Surviving Sepsis Campaign (SSC) guidelines. This study aimed to explore and identify barriers to the implementation of the sepsis bundles and strategies to enhance healthcare providers' adherence to these bundles. A systematic review of articles was conducted using the ACE Star Model of Knowledge Transformation. Studies such as randomized controlled trials (RTC's), systematic reviews, retrospective studies, and prospective observational studies conducted in Intensive Care Units (ICUs) within the past 10 years were utilized, guided by the American Association of Critical Care Nurses' (AACN's) grading system. Sources of evidence were obtained from PubMed, CINAHL, and GoogleScholar. The results of this study are aimed at helping support the evidence-based clinical practice among providers caring for patients with sepsis and septic shock in an ICU setting using evidence-based guidelines. The results of this study provide an opportunity for healthcare systems to relieve financial burdens from sepsis and thus contribute to pos