Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2016-09-15T18:30:05Z No. of bitstreams: 1 mauriciodenassaumachado_tese.pdf: 15169790 bytes, checksum: 44c4bba3d0bddeb188ec239527b863f1 (MD5) / Made available in DSpace on 2016-09-15T18:30:05Z (GMT). No. of bitstreams: 1 mauriciodenassaumachado_tese.pdf: 15169790 bytes, checksum: 44c4bba3d0bddeb188ec239527b863f1 (MD5) Previous issue date: 2014-05-07 / Introduction: Acute kidney injury is a complex syndrome characterized by rapid (hours or days) reduction in renal excretion that occurs in a wide variety of situations. It has wide variability of epidemiology and is a common complication in critically ill and intensive care patients. Acute kidney injury generate increased hospital costs and is associated with high mortality rates being independent predictor of death. Currently, three diagnostic criteria for acute kidney injury has been highlighted: RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease), AKIN (Acute Kidney Injury Network) and KDIGO (Kidney Disease: Improving Global Outcomes). Objectives: To evaluate the incidence, morbidity and mortality associated with acute kidney injury (and its value as a predictor of 30-day mortality) in patients undergoing on-pump coronary artery bypass grafting (article 1), patients undergoing cardiac valve surgery (article 2), patients with elevated preoperative baseline creatinine (article 3) and, in general, in patients undergoing cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) (article 4). Methods: (Article 1) Patients undergoing on-pump CABG from January 2003 to January 2008 (817 patients) were divided according to the AKIN classification in AKI (+) and AKI (-) patients. Multivariable logistic regression was used to determine independent predictors of 30-day mortality. (Article 2) Patients undergoing cardiac valve surgery from January 2003 to May 2010 (837 patients) were divided according to the presence of infective endocarditis. Cox regression analysis was used to determine independent predictors of 30-day mortality. (Article 3) Patients with elevated baseline serum creatinine underwent cardiac surgery (CABG or CVS) from January 2003 to June 2013 (918 patients) were evaluated to determine whether the development of post-operative acute kidney injury based on KDIGO criteria was an independent predictor of 30-day mortality. (Article 4) Patients undergoing cardiac surgery (CABG or CVS) between January 2003 and June 2013 (2804 patients) were evaluated to determine if acute kidney injury based on KDIGO criteria was an independent predictor of 30-day mortality. Results: (all articles) Patients who developed AKI postoperatively had more clinical complications. The 30-day mortality increased progressively in all stages of acute kidney injury. Based on AKIN and KDIGO criteria, AKI was an independent predictor of 30-day mortality. Conclusions: (all articles) In this population, acute kidney injury after cardiac surgery was an independent predictor of 30-day mortality. / Introdução: Disfunção renal aguda é uma síndrome complexa caracterizada pela rápida (horas ou dias) redução da excreção renal que ocorre em uma grande variedade de situações. Ela tem ampla variabilidade epidemiológica e é complicação comum em pacientes gravemente enfermos e de terapia intensiva gerando aumento dos custos hospitalares e associando-se a altas taxas mortalidade sendo preditor independente do risco de morte. Atualmente, três critérios diagnósticos para lesão renal aguda tem se destacado: RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease), AKIN (Acute Kidney Injury Network) e KDIGO (Kidney Disease: Improving Global Outcomes). Objetivos: Avaliar a incidência, morbidade e mortalidade associada a lesão renal aguda (e seu valor como preditor de óbito em 30 dias) em pacientes submetidos a cirurgia de revascularização do miocárdio com CEC, pacientes submetidos a cirurgia valvar, pacientes com creatinina basal elevada no pré-operatório e, de maneira global, em pacientes submetidos a cirurgia cardíaca (revascularização do miocárdio ou cirurgia valvar). Métodos: (artigo 1) Pacientes submetidos a RM com CEC no período de janeiro de 2003 a janeiro de 2008 (817 pacientes) foram divididos de acordo com a classificação AKIN em LRA (+) e LRA (-). Regressão logística multivariada foi utilizada para determinação de preditores independentes para óbito em 30 dias; (artigo 2) Pacientes submetidos a cirurgia valvar no período de janeiro de 2003 a maio de 2010 (837 pacientes) foram divididos de acordo com a presença de endocardite infecciosa. Regressão de Cox foi usada para determinar preditores independentes para óbito em 30 dias; (artigo 3) Pacientes portadores de creatinina basal elevada (pré-operatório) submetidos a cirurgia cardíaca (RM ou CV) entre janeiro de 2003 a junho de 2013 (918 pacientes) foram avaliados para determinar se o desenvolvimento de lesão renal aguda pós-operatória baseada nos critérios KDIGO foi preditor independente de óbito em 30 dias; (artigo 4) Pacientes submetidos a cirurgia cardíaca (RM ou CV) entre janeiro de 2003 a junho de 2013 (2804 pacientes) foram avaliados para determinar se o desenvolvimento de lesão renal aguda pós-operatória baseada nos critérios KDIGO foi preditor independente de óbito em 30 dias. Resultados: (todos artigos) Pacientes que evoluíram com LRA tiveram mais complicações no pós-operatório. A mortalidade em 30 dias aumentou progressivamente em todos os estágios de lesão renal aguda. Baseado nos critérios AKIN e KDIGO, LRA foi preditor independente de óbito em 30 dias. Conclusões: (todos artigos) Na população estudada, alteração aguda da função renal no pós-operatório foi preditor independente de óbito em 30 dias.

Objetivos: determinar a taxa de falha da ventilação não invasiva (VNI) em crianças em pós operatório (PO) de cirurgia cardíaca com insuficiência respiratória (IResp) pós extubação e identificar seus fatores preditivos de sucesso. Tipo de estudo: coorte prospectivo. Local: Unidade de terapia intensiva pediátrica de três hospitais terciários de São Paulo, Brasil. Sujeitos: Pacientes consecutivos pediátricos menores que 18 anos com diagnóstico de cardiopatia congênita que foram submetidos a cirurgia cardíaca corretiva ou paliativa e apresentaram IResp em até 48 horas após a extubação sendo tratados com VNI. Intervenção: nenhuma. Métodos e resultados principais: a coleta de dados foi realizada entre 2011 e 2014, analisados 170 pacientes. Foi considerado falha da VNI a necessidade de reintubação orotraqueal em até 48 horas após o término do uso da VNI. Nenhum paciente apresentou parada cardiorrespiratória durante o uso da VNI, nem outra complicação que interrompesse seu uso. 61,8% tiveram sucesso na utilização de VNI, não necessitando de reintubação. A mediana de idade foi de 2 meses. Os sujeitos foram divididos em grupo sucesso da VNI e falha para a análise. A análise estatística foi realizada com os testes qui-quadrado, Mann-Whitney ou testes t-Student, realizada após a regressão logística univariada e multivariada para os com p < 0,05. As seguintes variáveis não apresentaram diferença estatística, entre os grupos: tempo circulação extracorpórea (p=0,669), hipertensão pulmonar (p=0,254), síndrome genética (p=0,342), RACHS-1 (p=0,097), idade (p=0,098), tempo ventilação mecânica invasiva (VMI) (p=0,186) e tempo VNI (p=0,804). O sexo masculino apresentou maior incidência de sucesso da VNI com p=0,013. Todos os parâmetros ventilatórios utilizados na VNI foram coletados e apresentaram p < 0,05. Na análise multivariada, apenas influenciaram na ocorrência de falha da VNI o gradiente de pressão mínimo (OR 1,45 com p=0,007), a saturação de pulso de oxigênio (SpO2) máxima (OR 0,88 com p=0,011) e a fração inspirada de oxigênio (FiO2) máxima (OR 1,16 com p < 0,001). Conclusão: VNI pode ser utilizada com sucesso em crianças em PO de cirurgia cardíaca que desenvolveram IResp nas 48 horas subsequentes à extubação, utilização de maior gradiente de pressão e maiores FiO2 são fatores associados com maior falha da utilização da VNI, utilização da VNI é segura sem a ocorrência de eventos adversos que impossibilitassem a utilização desta terapêutica / Objectives: To determine the rate of failure of noninvasive ventilation (NIV) in postoperative (PO) cardiac surgery in pediatric patients with respiratory failure (RF) after extubation and to identify predictive success factors. Design: prospective cohort study. Setting: Pediatric intensive care unit of three tertiary hospitals in São Paulo, Brazil. Patients: Consecutive pediatric patients under 18 years of age with diagnosis of congenital heart disease who underwent corrective or palliative heart surgery and presented RF within 48 hours after extubation and were treated with NIV. Intervention: none. Measurements and main results: data collected between 2011 and 2014, from 170 patients with 2 months median age. The need for orotracheal reintubation within 48 hours after the end of NIV was considered as NIV failure. No patient presented cardiorespiratory arrest during the use of NIV, nor another complication that interrupted its use. Overall, 61.8% were successful in the use of NIV, not requiring reintubation. Subjects were divided for analysis into successful and failed NIV groups. Statistical analysis used chi-square, Mann-Whitney or Student-t tests, performed after univariate and multivariate logistic regression, for p < 0.05. In the multivariate analysis, only the minimal pressure gradient (OR 1.45 with p = 0.007), the maximum oxygen saturation (SpO2) (OR 0.88 with p = 0.011) and the maximum inspiratory oxygen fraction (FiO2) (OR 1.16 with p < 0.001) influenced NIV failure. All ventilatory parameters used in NIV were collected and affected NIV success, with p < 0.05. The following variables did not present statistical difference between the groups: extracorporeal circulation time (p = 0.669), pulmonary hypertension (p = 0.254), genetic syndrome (p = 0.342), RACHS-1 (p = 0.097), age (p = 0.098), invasive mechanical ventilation (IMV) duration (p = 0.186) and NIV duration (p = 0.804). Conclusion: NIV can be successfully used in children in cardiac surgery postoperative who developed RF in the 48 hours following extubation. Use of higher pressure gradients and higher FiO2 associate with greater failure of NIV use. NIV use is safe, without occurrence of adverse events that prevent its use

Objetivos: determinar a taxa de falha da ventilação não invasiva (VNI) em crianças em pós operatório (PO) de cirurgia cardíaca com insuficiência respiratória (IResp) pós extubação e identificar seus fatores preditivos de sucesso. Tipo de estudo: coorte prospectivo. Local: Unidade de terapia intensiva pediátrica de três hospitais terciários de São Paulo, Brasil. Sujeitos: Pacientes consecutivos pediátricos menores que 18 anos com diagnóstico de cardiopatia congênita que foram submetidos a cirurgia cardíaca corretiva ou paliativa e apresentaram IResp em até 48 horas após a extubação sendo tratados com VNI. Intervenção: nenhuma. Métodos e resultados principais: a coleta de dados foi realizada entre 2011 e 2014, analisados 170 pacientes. Foi considerado falha da VNI a necessidade de reintubação orotraqueal em até 48 horas após o término do uso da VNI. Nenhum paciente apresentou parada cardiorrespiratória durante o uso da VNI, nem outra complicação que interrompesse seu uso. 61,8% tiveram sucesso na utilização de VNI, não necessitando de reintubação. A mediana de idade foi de 2 meses. Os sujeitos foram divididos em grupo sucesso da VNI e falha para a análise. A análise estatística foi realizada com os testes qui-quadrado, Mann-Whitney ou testes t-Student, realizada após a regressão logística univariada e multivariada para os com p < 0,05. As seguintes variáveis não apresentaram diferença estatística, entre os grupos: tempo circulação extracorpórea (p=0,669), hipertensão pulmonar (p=0,254), síndrome genética (p=0,342), RACHS-1 (p=0,097), idade (p=0,098), tempo ventilação mecânica invasiva (VMI) (p=0,186) e tempo VNI (p=0,804). O sexo masculino apresentou maior incidência de sucesso da VNI com p=0,013. Todos os parâmetros ventilatórios utilizados na VNI foram coletados e apresentaram p < 0,05. Na análise multivariada, apenas influenciaram na ocorrência de falha da VNI o gradiente de pressão mínimo (OR 1,45 com p=0,007), a saturação de pulso de oxigênio (SpO2) máxima (OR 0,88 com p=0,011) e a fração inspirada de oxigênio (FiO2) máxima (OR 1,16 com p < 0,001). Conclusão: VNI pode ser utilizada com sucesso em crianças em PO de cirurgia cardíaca que desenvolveram IResp nas 48 horas subsequentes à extubação, utilização de maior gradiente de pressão e maiores FiO2 são fatores associados com maior falha da utilização da VNI, utilização da VNI é segura sem a ocorrência de eventos adversos que impossibilitassem a utilização desta terapêutica / Objectives: To determine the rate of failure of noninvasive ventilation (NIV) in postoperative (PO) cardiac surgery in pediatric patients with respiratory failure (RF) after extubation and to identify predictive success factors. Design: prospective cohort study. Setting: Pediatric intensive care unit of three tertiary hospitals in São Paulo, Brazil. Patients: Consecutive pediatric patients under 18 years of age with diagnosis of congenital heart disease who underwent corrective or palliative heart surgery and presented RF within 48 hours after extubation and were treated with NIV. Intervention: none. Measurements and main results: data collected between 2011 and 2014, from 170 patients with 2 months median age. The need for orotracheal reintubation within 48 hours after the end of NIV was considered as NIV failure. No patient presented cardiorespiratory arrest during the use of NIV, nor another complication that interrupted its use. Overall, 61.8% were successful in the use of NIV, not requiring reintubation. Subjects were divided for analysis into successful and failed NIV groups. Statistical analysis used chi-square, Mann-Whitney or Student-t tests, performed after univariate and multivariate logistic regression, for p < 0.05. In the multivariate analysis, only the minimal pressure gradient (OR 1.45 with p = 0.007), the maximum oxygen saturation (SpO2) (OR 0.88 with p = 0.011) and the maximum inspiratory oxygen fraction (FiO2) (OR 1.16 with p < 0.001) influenced NIV failure. All ventilatory parameters used in NIV were collected and affected NIV success, with p < 0.05. The following variables did not present statistical difference between the groups: extracorporeal circulation time (p = 0.669), pulmonary hypertension (p = 0.254), genetic syndrome (p = 0.342), RACHS-1 (p = 0.097), age (p = 0.098), invasive mechanical ventilation (IMV) duration (p = 0.186) and NIV duration (p = 0.804). Conclusion: NIV can be successfully used in children in cardiac surgery postoperative who developed RF in the 48 hours following extubation. Use of higher pressure gradients and higher FiO2 associate with greater failure of NIV use. NIV use is safe, without occurrence of adverse events that prevent its use

This thesis describes the management of patients treated with mechanical circulatory support devices for short- or long-term use. Twenty-four patients suffering from postcardiotomy heart failure were treated with a minimally invasive axial flow pump. The device was effective in unloading the failing left ventricle and in maintaining an adequate systemic circulation. The principles of perioperative monitoring, and pharmacological therapy are outlined. The pump was also used as an alternative to the heart-lung machine in conjunction with coronary artery bypass surgery. Together with a short-acting β-blocker, esmolol, the heart was decompressed and heart motion was reduced, facilitating bypass surgery on the beating heart. The anesthesiological considerations using this method are described. An implantable left ventricular assist device was used as a bridge to heart transplantation in 10 patients. We were interested in assessing the possibility to establish such a treatment program at a non-transplanting center. A multidisciplinary approach was enabled thanks to the organization of our Heart Center and due the close collaboration with our transplant center at Lund University. As one of the first centers in Europe, we established a well-functioning program with good results. Nine out of 10 of the bridge patients, with treatment times varying between 53 to 873 days, survived pump treatment and were eventually transplanted. The device proved to be powerful enough to support the failing heart and enable rehabilitation of the patients. Outpatient management became simpler when using the electrical device with belt-worn batteries. The uncertain durability and the high risk of device-related complications are shortcomings that limit its potential for more permanent treatment of heart failure. A new generation of small implantable axial blood flow pumps has therefore been developed. The principles of these pumps are based on the first generation axial flow pumps evaluated in this thesis. After several years of basic research and experimental studies, the first human implants have been performed. In the thesis, the hemodynamic effects of such a novel axial flow pump have been evaluated in an acute heart failure model. This technology holds great promise, both as a bridge to heart transplantation, and as a permanent circulatory support system. / On the day of the public defence the status of the article IV was: Submitted for publication.

Chlamydophila pneumoniae (C. pneumoniae) has been suggested as a stimulator of chronic inflammation in atherosclerosis. C. pneumoniae DNA was demonstrated in aortic biopsies in 50% of patients with stable angina pectoris or acute coronary syndrome undergoing coronary artery bypass grafting. C. pneumoniae mRNA, a marker of replicating bacteria, was demonstrated in 18% of the aortic biopsies. Inflammation may have a role in the pathogenesis of thoracic aortic aneurysm, aortic dissection and aortic valve stenosis. C. pneumoniae DNA was demonstrated in aortic biopsies in 26% of thoracic aortic aneurysm patients and in 11% of aortic dissection patients undergoing thoracic surgery and in 22% of stenotic aortic heart valves from patients undergoing aortic valve replacement. No bacterial mRNA was demonstrated in these aortic biopsies, nor in the valves, suggesting that the infection has passed into a persistent state. C. pneumoniae DNA was demonstrated in peripheral blood mononuclear cells in only 5% of aortic valve stenosis patients and not in thoracic aortic aneurysm or aortic dissection patients, suggesting that the bacterium disseminated to the cardiovascular tissue long before the patient required surgery. The copper/zinc ratio in serum, a marker of infection/inflammation, was significantly elevated in thoracic aortic aneurysm patients, supporting an inflammatory pathogenesis. Patients positive for C. pneumoniae in the aortic valve had more advanced coronary atherosclerosis, further supporting a possible role for C. pneumoniae in atherosclerosis. Mice were infected with C. pneumoniae that disseminated to all organs investigated (i.e. lungs, heart, aorta, liver and spleen). Trace element concentrations were altered in infected animals with an increased copper/zinc ratio in serum, a progressively increased iron concentration in the liver and a progressively decreased iron concentration in serum. Iron is important for C. pneumoniae metabolism, and a changed iron homeostasis was noted in infected mice by alterations in iron-regulating proteins, such as DMT1 and hepcidin.

In cardiac surgery, sternal wound infection (SWI) continues to be one of the most serious postoperative complications. Coagulase-negative staphylococci (CoNS) have become the most common causative agents of SWI. Prophylaxis with intravenous beta-lactam antibiotics (cephalosporins or in Sweden most commonly isoxazolyl penicillins) is routinely practised. However, many CoNS species are resistant to beta-lactam antibiotics. Vancomycin is often the only effective antibiotic available for treatment of these infections, but its use for routine prophylaxis is strongly discouraged because of the risk of increasing the selection of resistant bacteria. The aim of this work was to develop and evaluate a new technique for antibiotic prophylaxis in cardiac surgery consisting of application of drug eluting collagen-gentamicin sponges in the sternal wound in addition to conventional intravenous antibiotics. The antibiotic concentrations in the wound and serum achieved by routine intravenous dicloxacillin prophylaxis and those after application of local collagen-gentamicin in the sternal wound were investigated. These studies showed dicloxacillin levels adequate for prevention of infections by methicillin-susceptible staphylococci, and extremely high gentamicin levels in the wound fluid, during the first 8-12 hours postoperatively with the local application. Two thousand cardiac surgery patients were then randomised to routine prophylaxis with intravenous isoxazolyl penicillin alone (control group) or to this prophylaxis combined with application of collagen-gentamicin (260 mg gentamicin) sponges within the sternotomy before wound closure. The primary end-point was any sternal wound infection within two months postoperatively. Evaluation was possible in 983 and 967 patients in the treatment and control groups, respectively. The incidence of any sternal wound infection was 4.3% in the treatment group and 9.0 % in the control group (relative risk = 0.47, (95% confidence interval 0.33 to 0.68); P&lt;0.001). The most common microbiological agents were CoNS, followed by Staphylococcus aureus. Local gentamicin reduced the incidence of SWIs caused by all major, clinically important microbiological agents except Propionibacterium acnes. Assignment to the control group, high body mass index, diabetes mellitus, younger age, single or double internal mammary artery, left ventricular ejection fraction less than 35% and longer operation time were independent risk factors for SWI in a multivariable risk factor analysis. In patients with additional sternal fixation wires (&gt; six wires) the collagen-gentamicin prophylaxis was associated with an approximately 70 % reduction in the incidence of SWI at all depths and the application of collagen sponges between sternal halves may require particular attention regarding the stability of fixation. A cost effectiveness analysis showed that the application of local collagen-gentamicin as prophylaxis was dominant, i.e. resulted in both lower costs and fewer wound infections. Routine use of the described prophylaxis in all adult cardiac surgery patients could be recommended.

<p>The aims of the practical work carried out for this thesis were to redesign a clinical decision support system for thoracic surgeons, called AssistMe, and to evaluate the concept behind this system. The main objective of the thesis is to give an account of the considerations that were found to be of key importance for designing a clinical decision support system for thoracic surgery. Another aim was to let future users test the system after it had been redesigned and evaluate the concept behind it. The thesis also investigates users’ experience of the system and their views on whether it would be applicable in their daily work practice. An account is also given of experience of using QOC-notation during the design space analysis in a real design project like this one.</p>

Objetivo: Avaliar a efetividade e o momento ideal da realização da toracoscopia vídeoassistida (TVA) para o tratamento de crianças com derrame pleural parapneumônico complicado (DPPC), bem como determinar se a drenagem torácica realizada como procedimento inicial pode influenciar os resultados da TVA. Métodos: Estudo retrospectivo de 79 crianças (idade média de 35 meses) submetidas à TVA, entre janeiro de 2000 e dezembro de 2011. Os pacientes foram tratados com o mesmo algoritmo de tratamento e os procedimentos cirúrgicos foram realizados ou supervisionados pelo mesmo cirurgião. As crianças foram divididas em dois grupos de acordo com o intervalo de quatro dias entre o diagnóstico do DPPC e a cirurgia. Resultados: Pacientes operados até o 4º dia após o diagnóstico do DPPC apresentaram menor tempo de internação (p=0,008), de uso de antibióticos (p=0,023) e de uso de dreno torácico (p=0,019), além de serem submetidos a menor número de procedimentos cirúrgicos (p<0,001). A drenagem pleural prévia retardou a realização da TVA em três dias, com consequente aumento no tempo de internação (p=0,050), no tempo de permanência do dreno torácico (p<0,001) e no tempo cirúrgico da TVA (p<0,001). TVA foi eficaz em 73 crianças (92,4%). Nem o intervalo entre o diagnóstico e a cirurgia, nem a drenagem pleural prévia, influenciaram a taxa de insucesso da TVA. Conclusões: TVA é um procedimento altamente efetivo em crianças com DPPC. TVA realizada até quatro dias após o diagnóstico do DPPC está associada à redução nos tempos de internação, de permanência do dreno torácico e do uso de antibióticos, além de diminuição no número de intervenções invasivas. / thoracoscopic surgery (VATS) in the treatment of children with complicated parapneumonic pleural effusion (CPPE) and to determine whether the use of initial chest tube drainage (CTD) may influence VATS outcome. Methods: We retrospectively reviewed medical records of 79 children (mean age, 35 months) undergoing VATS from January 2000 to December 2011. The same treatment algorithm was used in the management of all patients, and all surgical procedures were performed or supervised by the same surgeon. The children were divided into two groups according to a 4-day interval between CPPE diagnosis and surgery. Results: Patients undergoing VATS within 4 days of CPPE diagnosis had a shorter hospital stay (p=0.008), fewer number of antibiotics administered (p=0.023), and decreased time with a chest tube (p=0.019), in addition to undergoing fewer number of surgical procedures (p<0.001). Initial CTD resulted in a delay of 3 days in performing VATS, leading to longer hospital stay (p=0.050), increased time with a chest tube (p<0.001), and longer VATS operating time (p<0.001). VATS was effective in 73 children (92.4%). The interval from diagnosis to surgery and initial CTD had no influence on VATS failure rate. Conclusions: VATS is a highly effective procedure for treating children with CPPE. VATS performed within 4 days of CPPE diagnosis is associated with shorter hospital stay, decreased time with a chest tube, fewer antibiotics administered, and fewer invasive interventions.

Made available in DSpace on 2014-06-11T19:25:36Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-02-12Bitstream added on 2014-06-13T19:32:57Z : No. of bitstreams: 1 tonon_e_me_botfm.pdf: 621514 bytes, checksum: f42de067077b49bbfe8b27db1ee8aff3 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Apesar da fisioterapia respiratória aparentemente beneficiar pacientes sob ventilação mecânica, não há evidências suficientes para sua recomendação. Usando associação das manobras compressão torácica (CT) e hiperinsuflação manual (HM), prévio estudo de nosso grupo identificou significante redução no período de ventilação mecânica (VM), no período de internação e melhora da extensão de lesão pulmonar (Murray) em pacientes sob VM. Contudo, é desconhecido o papel isolado de cada manobra nos benefícios encontrados. Portanto, o objetivo deste estudo foi comparar prospectivamente o efeito isolado e associado das manobras CT e HM no período de internação e de VM em pacientes sob VM. O estudo foi conduzido por 13 meses na UTI (Pronto-Socorro do Hospital das Clínicas, UNESP, Botucatu, SP, Brasil) de um hospital universitário terciário. Foi também avaliada a interferência das manobras nos seguintes parâmetros: índice prognóstico (APACHE-II), Murray, oxigenação (PaO2/FiO2), mecânica respiratória, repercussões hemodinâmicas e saturação periférica de oxigênio (SpO2). A análise estatística utilizou o teste de Goodman para contrastes entre e dentro de populações multinomiais, qui-quadrado, análise de variância e análise de variância para o modelo de medidas repetidas em grupos independentes. Dos 204 pacientes que preencheram os critérios de inclusão e exclusão e foram admitidos no estudo, 20 pacientes foram alocados no grupo CT, 20 no grupo HM e 20 no grupo CT+HM de acordo com o processo de sistematização. Diversas causas levaram à exclusão de alguns pacientes durante o estudo e cada grupo passou a ser constituído por 15 pacientes. O grupo CT recebeu compressão torácica, o grupo HM recebeu hiperinsuflação manual e o grupo CT+HM recebeu a associação de ambas as manobras duas vezes ao dia durante cinco... / There is no evidence to support the recommendation of chest physiotherapy on mechanically ventilated (MV) patients, although this procedure apparently improves those patients. Using association of thoracic compression (TC) and manual hyperinflation (MH), our previous study identified significant reduction in duration of weaning from ventilation, discharge from intensive care unit (ICU) and extent of lung damage index (Murray). However, it is unknown the individual role of each maneuver on those benefits. Therefore, the aim of the study was evaluate the isolated and associated effect of TC and MH on the mechanical ventilation period and length of stay in mechanically ventilated patients. Secondarily, outcomes of interest were the effect of physiotherapy on Murray, severity score and on hemodynamics, gas exchange, and respiratory mechanics. It was conducted at ICU of the Emergency Room (ER) at Hospital das Clínicas of São Paulo State University (UNESP-HC) (Botucatu, SP, Brazil) for 13 consecutive months. The significance of differences between groups was accessed by Goodman test, chi-squared analysis, ANOVA and a nonparametric repeated measures ANOVA. The present study was a three-group (TC, MH, and TC+MH), prospective and systematized clinical study lasting 5 days. Of the 204 patients who fulfilled all the inclusion criteria and were enrolled in the study, 20 patients were allocated into TC group, 20 into MH group or 20 into TC+HM group. The TC group received expiratory chest compression, the MH group received manual hyperinflation and the TC+HM received manual hyperinflation combined with expiratory chest compression twice a day for 5 days. Five patients from TC, 5 from MH and 5 from TC+HM were withdrawn during the study period due to several reasons and therefore, 15 patients remained in each group. The 3 groups... (Complete abstract click electronic access below)

Introduction Prior to percutaneous coronary intervention (PCI) guidelines recommend that patients with ST- elevation myocardial infarction (STEMI) receive dual antiplatelet therapy (DAPT) consisting of P2Y12 inhibition and acetylsalicylic acid (aspirin). However, in rare occasions, patients admitted with STEMI as preliminary diagnosis require acute thoracic surgery and oral P2Y12 inhibitors increases the bleeding risk over several hours. Cangrelor is an intravenous reversible P2Y12 antagonist with normal platelet function returning within 60 minutes and might therefore be an attractive alternative to oral P2Y12 inhibition.Aim Firstly, to quantify P2Y12 pre-treatment with ticagrelor in patients undergoing acute thoracic surgery and the mortality and morbidity rate associated with DAPT prior to surgery. Secondly, to estimate cost-benefit differences between cangrelor and ticagrelor pre-treatment.Material and Methods A descriptive cohort study using retrospective data. The inclusion criteria were patients undergoing acute thoracic surgery (≤ 24 hours) between January 2015 and December 2017, in the catchment area of Örebro University Hospital. Patients were stratified into groups depending on whether they had received pre-treatment with DAPT or not before surgery. Statistical analyses were made in SPSS and Excel.Results A total of 50 patients were included. 8 patients received DAPT before surgery. There was no mortality in patients receiving DAPT but TIMI major bleeding was more frequent compared to the group with no pre-treatment. The DAPT group required numerically more units of platelets and plasma, however the result was not significant. Direct treatment costs for ticagrelor was 20.14 SEK (the dosage is 2 tablets) and cangrelor was 3 059 SEK.Conclusions DAPT pre-treatment with ticagrelor was not associated with increased mortality but TIMI major bleeding was more frequent compared to the group with no pre-treatment. Direct treatment costs with cangrelor was higher compared to ticagrelor treatment. Further studies, with larger study samples, are needed to investigate complications associated with P2Y12 pre-treatment in patients undergoing acute thoracic surgery.