Orientadora: Márcia Rita Fernandes Machado / Banca: Maria Rita Pacheco / Banca: Maria Angélica Dias / Resumo: Considerando-se que a paca (Cuniculus paca) é o segundo maior roedor da fauna brasileira, a pesquisa sobre estes animais vem tornando-se importante, pois além de haver grande interesse na sua criação comercial, já que apresentam carne de excelente qualidade, sendo roedores, podem vir a tornar-se animais alternativos para a experimentação, e ainda, como poucas são as informações detalhadas sobre sua morfologia, objetivou-se com este trabalho descrever a morfologia, morfometria e a ultraestrutura de segmentos das porções torácica e abdominal da aorta e segmentos das porções cranial e caudal da veia cava de quatro pacas (Cuniculus paca) machos e fêmeas. Parte dos segmentos foi analisada à microscopia de luz e parte, à microscopia eletrônica de varredura. Mensurou-se as espessuras do complexo formado pelas túnicas íntima+média e túnica adventícia da aorta e veia cava e analisou-se os resultados pela estatística descritiva, teste "T" pareado (p<0,05) e teste de Tukey (p<0,05). Em relação à espessura das túnicas estudadas, notou-se que, em todos os animais, os valores referentes à espessura do complexo formado pelas túnicas íntima+média da aorta torácica cranial foram significativamente maiores, quando comparados aos valores dos outros segmentos aórticos analisados; na veia cava comprovou-se que os valores da espessura das túnicas íntima, média e adventícia, para todos os animais, foram significativamente maiores no segmento cranial. As camadas das paredes dos vasos apresentaram variações entre si quanto à estrutura e espessura, supostamente devido a uma adaptação à exigência funcional / Abstract: Considering that the paca (Cuniculus paca) is the second largest rodent of the Brazilian fauna, researches concerning these animals are becoming important because the wide interest on its commercial production since they have excellent meat quality and as rodents they could become alternatives to animal experimentation. As there is few detailed information on their morphology, the aim of this study is describe the morphology, morphometry and ultrastructure of segments of thoracic and abdominal aorta portions and segments of cranial and caudal vena cava portions in four males and females Cuniculus paca. Part of the segments were examined by light microscopy and part by scanning electron microscopy. Thickness measures of the tunica intima and media complex and tunica adventitia of the aorta and vena cava were taken and analyzed using "T" test (p <0.05) and Tukey test (p <0.05). In all animals the thickness values for the tunica intima and media complex of the cranial thoracic aorta were significantly higher when compared to the values of other aortic segments analyzed; in vena cava the thickness values of the intima, media and adventitia, for all animals, were significantly higher in the cranial segment. The layers of the vessel walls show variations in structure and thickness, presumably due to an adaptation to functional demand / Mestre

Orientadores: Nelson Adami Andreollo, Luis Alberto Magna / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-08T15:51:23Z (GMT). No. of bitstreams: 1 Leonardi_MariliaIracema_D.pdf: 4399596 bytes, checksum: c65fb389f14c8904f8d2f86459121589 (MD5) Previous issue date: 2006 / Resumo: A técnica de transplante ortotópico de fígado (TOF) com preservação da veia cava inferior retro-hepática, conhecida por "piggyback" assegura estabilidade hemodinâmica durante a hepatectomia do receptor. Contudo, têm sido relatadas complicações sistêmicas,sobretudo respiratórias e renais, além de persistência de ascite, no pós-operatório dos pacientes submetidos a TOF com a técnica de "piggyback". O estudo é retrospectivo e tem por objetivo avaliar as limitações para execução do TOF à "piggyback", estudar o comportamento hemodinâmico intra-operatório e analisar as complicações pós-operatórias mais diretamente relacionadas à técnica. A casuística é composta por 275 pacientes, selecionados entre os 315 transplantes realizados na Unidade de Transplante Hepático da Universidade Estadual de Campinas, no período de setembro de 1991 a dezembro de 2005. Os pacientes foram divididos em quatro grupos, de acordo com o tipo de reconstrução da veia cava inferior, a saber: Grupo ST: pacientes transplantados com a técnica convencional (n=37); Grupo PB3: pacientes transplantados com a técnica de "piggyback" e reconstrução da veia cava inferior com anastomose término-terminal entre os óstios das três veias hepáticas do receptor com o óstio da veia cava supra-hepática do enxerto (n=117); Grupo PB2: pacientes transplantados com a técnica de "piggyback" e reconstrução da veia cava inferior com anastomose término-terminal entre os óstios de duas veias hepáticas do receptor com o óstio da veia cava supra-hepática do enxerto (n=101); Grupo PBLL: pacientes transplantados com a técnica de "piggyback" e cavotomia, com anastomose látero-lateral, "face-a-face" ou término-lateral (n=20). Os grupos foram comparados, quanto aos parâmetros estudados, por meio do teste do Chi quadrado ou teste exato de Fisher. O nível de significância adotado foi de 5%. Não há diferenças entre os grupos quanto ao sexo e etiologia da doença hepática crônica. Há maior prevalência de pacientes Child-Pugh C no grupo PB2, cuja idade média é superior aos demais. Os resultados obtidos mostram que a técnica de "piggyback" pôde ser empregada em 91,5% dos pacientes. A queda de pressão arterial média foi mais acentuada, após a reperfusão, nos grupos PBL e ST. As maiores elevações de PMAP ocorreram nos grupos PB2 (p=0,025) e PB3 (p=0,038) na fase anepática e cinco minutos após a reperfusão, respectivamente. Os valores médios de PVC, PCP e DC são semelhantes entre os grupos nos cinco tempos estudados. A prevalência de ascite foi baixa em todos os grupos estudados. Há forte tendência a maior prevalência de complicações respiratórias no grupo PBL (p=0,054). A necessidade de reoperação por sangramento e de hemodiálise no pós-operatório foram semelhantes entre os grupos. A sobrevida média global aos 30 dias de pós-operatório foi de 78,2%, sendo semelhante entre os grupos. A técnica de "piggyback" permite reduzir os tempos operatório e de isquemia quente, e ainda o consumo intra-operatório de hemoderivados / Abstract: The technique of orthtotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation, known as "piggyback", assures hemodynamic stability during recipient hepatectomy, which avoids tissue hypoperfusion. However post-operative complications, mainly renal and respiratory, have been described. The study is retrospective and aims to evaluate the aplicability of "piggyback" OLT and analyse post-operative complications more directly related to the surgical technique. From September 1991 to December 2005, 275 patients with mean age of 43±13 years were submitted to OLT and divided into four groups: Group ST: no preservation of retro-hepatic IVC (n=37); Group PB3: piggyback OLT and IVC reconstruction with three recipient hepatic veins (n=117); Group PB2: piggyback OLT and IVC reconstruction with two recipient hepatic veins (n=101); Group PBLL: piggyback OLT and IVC reconstruction with cavotomy and lateralateral anastomosis (n=20). Gropus were compared by Chi square test and exact test, with p<0.05. There was no difference regarding sex and chronic liver disease etiology. The majority of them are Child-Pugh class C and the mean age of group PB2 was higher than the others. Piggyback OLT colud be employed in 91,5% of patients. MAP decreased significantly in group PB2 an PBL at 15 minutes after reperfusion (p<0.001). MPAP showed greater increase in goup PBL (p=0.008) 15 minutes after graft reperfusion. Mean values of CVP, PCP and CO are comparable during recipient surgery. ST group showed longer warm ischemia and operative times compared to the others (p<0.01), as well as more blood products requirements. Cold ischemia time was similar among groups. Ascites prevalence was very low in the four groups. There is evident tendency to a higher prevalence of respiratory complications in group PBLL (p=0.054). Need for reoperation due to bleeding and hemodialyses were similar in all groups. Mean survival time was 78.2% on PO 30, without difference among groups / Doutorado / Cirurgia / Doutor em Cirurgia

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No. of bitstreams: 1 josemunizpazelijunior.pdf: 868943 bytes, checksum: 7c1afb9837b6e1d73d18f7ea10b1401f (MD5) Previous issue date: 2012-11-29 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A Doença Renal Crônica (DRC) é um problema de saúde pública mundial e o número de pacientes inscritos em programas de terapia de substituição de função renal vem crescendo progressivamente. A morbimortalidade dos pacientes com DRC é impressionante e se deve principalmente a doença cardiovascular. A remoção inadequada de líquidos durante a hemodiálise é um dos principais fatores responsáveis por esta evolução desfavorável. A hipervolemia crônica leva a hipertensão, hipertrofia ventricular esquerda, congestão pulmonar e aumenta as taxas de hospitalização e mortalidade. A hipovolemia, por outro lado, se associa com náuseas, vômitos, diminuição da qualidade de vida, perda da função renal residual, trombose do acesso venoso e redução da adequação da diálise, devido às frequentes interrupções das sessões de diálise. O peso seco, definido como o menor peso atingido pelo paciente no final das sessões, quando a maior parte do excesso de líquido acumulado tenha sido removido, ainda é avaliado clinicamente, mas tem fraca correlação com a verdadeira volemia. Apesar de não podermos contar com método que seja “padrão-ouro”, devido às limitações na acurácia e aplicabilidade, várias exames complementares tem sido estudados e validados para a determinação mais precisa da volemia em pacientes dialíticos, incluindo a avaliação ultrassonográfica da veia cava inferior (VCI). O alto custo dos ecocardiógrafos e a necessidade de um ecocardiografista para operá-los têm impedido a disseminação da ultrassonografia para avaliar a VCI e, consequentemente, a volemia. Nós hipotetizamos que a classificação volêmica baseada na determinação do diâmetro expiratório da VCI indexado pela superfície corpórea (DVCIi) e o índice de colabamento inspiratório da VCI (ICVCI) realizada por médico nefrologista, sem especialização em ultrassonografia, é similar àquela obtida no mesmo exame realizado por médico especialista em ecocardiografia utilizando um ecocardiógrafo padrão (ECO) ou um equipamento de ultrassom convencional (US). Neste estudo transversal, um ecocardiografista experiente e um nefrologista sem especialização formal em ultrassonografia avaliaram consecutivamente o DVCIi e o ICVCI de 52 pacientes, durante as sessões de hemodiálise. No protocolo I, o nefrologista usou o US e o cardiologista usou o ECO; no protocolo II os aparelhos foram invertidos entre os pesquisadores. Em ambos os protocolos, os coeficientes de Pearson e kappa foram utilizados para avaliar a correlação entre as variáveis contínuas e categóricas, respectivamente. A concordância entre os examinadores foi avaliada pelo Bland-Altman. Obtivemos imagens de boa qualidade da VCI em 96% dos pacientes. As avaliações do DVCIi apresentaram forte correlação em ambos os protocolos (r= 0,88 e 0,84, nos protocolos I e II, respectivamente). A correlação entre as classificações volêmicas foi excelente no protocolo I (kappa = 0,82 e 0,93 pelo DVCIi e ICVCI, respectivamente) e substancial no protocolo II (kappa = 0,77 e 0,75 pelo DVCIi e ICVCI, respectivamente). A concordância entre os examinadores pelo gráfico de Bland-Altman das avaliações de DVCIi foi também muito boa em ambos os protocolos. Nefrologistas sem especialização formal em ultrassonografia usando um US podem avaliar a volemia de pacientes dialíticos através da ultrassonografia de VCI. O mesmo equipamento que já equipa as clínicas de diálise e é utilizado para diversas outras finalidades, como biópsia renal guiada, acesso venoso guiado, avaliação do trato urinário, mapeamento vascular e estudo das fístulas e enxertos, pode ser utilizado para determinação do peso seco. Esperamos assim, reduzir custos e melhorar a qualidade do atendimento dos pacientes dialíticos, através da disseminação da avaliação ultrassonográfica da VCI. / Chronic kidney disease has emerged as a public health problem of substantial proportions, and the number of patients who require renal replacement therapy has been growing over the years. The mortality rate of patients with ESRD remains amazing, and a large part of this mortality is due to cardiovascular disease. The inadequate fluid removal during hemodialysis is a major factor responsible for this unfavorable development. The hypervolemia leads to chronic hypertension, left ventricular hypertrophy, pulmonary congestion and increased rates of hospitalization and mortality. The hypovolemia, moreover, is associated with nausea, vomiting, diminished quality of life, loss of residual renal function, access thrombosis and reduction of dialysis adequacy, due to frequent interruptions of dialysis sessions. Clinically estimated dry weight, defined as the lowest post-dialysis weight at which most excess body fluid will have been removed, is widely used but is poorly predictive of volemic status. Despite the lack of gold standards, related to limitations in accuracy and feasibility, fluid volume has been assessed by using various tools, including ultrasonographic evaluation of the inferior vena cava (IVC). We sought to determine whether a nephrologist with limited ultrasound training can accurately assess the IVC in patients undergoing haemodialysis compared with a cardiologist by using a regular ultrasound system (RUS) or a full cardiovascular ultrasound system (CVUS). In a cross-sectional study, an experienced cardiologist and a nephrologist without formal ultrasound training consecutively measured the indexed IVC expiratory diameter (VCDi) and IVC collapsibility index (IVCCI) of 52 patients during haemodialysis sessions. In protocol I, the nephrologist used an RUS and the cardiologist used a CVUS; in protocol II, the machines were interchanged. In both protocols, Pearson and kappa correlation coefficients were used to evaluate the 11 interobserver correlation of continuous and categorical data, respectively. The interexaminer agreement was determined by the Bland–Altman method. High-quality IVC images were obtained in 96% of the patients. The VCDi measurements showed strong correlation in both protocols (r = 0.88 and 0.84 in protocols I and II, respectively). The volaemic classifications were excellent in protocol I (kappa = 0.82 and 0.93 by the VCDi and IVCCI, respectively) and substantial in protocol II (kappa = 0.77 and 0.75 by the VCDi and IVCCI, respectively). The interexaminer agreement on the VCDi measurements was also very good in both protocols. Ultrasound evaluation of the IVC can be performed by nephrologists without formal training using an RUS to assess volaemic status in patients undergoing haemodialysis. The same equipment that is already being used in dialysis clinics for several other purposes, such as guided renal biopsy, guided venous access, evaluation of the urinary tract, vascular mapping and study of fistulas and grafts can be used to determine the dry weight. We hope reduce costs and improve the quality of care for dialysis patients, through the spread of ultrasound evaluation of the IVC.

Malgré des progrès significatifs dans le diagnostic précoce, on constate ces dernières années une nette tendance à l'augmentation du nombre de patients atteints de carcinome à cellules rénales (CCR) présentant une complication spécifique sous la forme d'un thrombus tumoral (TT) s'étendant le long de la lumière de la veine cave inférieure (VCI) au-dessus du niveau du diaphragme, jusqu'à l'atrium droit. Le seul traitement efficace du CCR avec TT reste la chirurgie. La chirurgie conventionnelle comprend la néphrectomie radicale avec thrombectomie, nécessitant des techniques de pontage cardio-pulmonaire et l'arrêt de la circulation sanguine, ce qui implique toujours des complications graves. Pour les éviter, diverses options d'accès chirurgical à la partie supradiaphragmatique de la VCI et à l'atrium droit ont été proposées exclusivement par le côté abdominal, en utilisant diverses options de diaphragmotomie et de péricardotomie avec isolement de la VCI dans la cavité péricardique. L'un des points les plus importants dans le traitement chirurgical du CCR avec TT supradiaphragmatique, est le contrôle de l'extrémité distale du TT. Cette étape dépend largement de l'accès choisi. Dans ce travail, afin d'optimiser les techniques chirurgicales pour les patients atteints de TT supradiaphragmatique, nous avons comparé la faisabilité et la sécurité des différents accès chirurgicaux transdiaphragmatiques. Nous avons également proposé un accès transdiaphragmatique transpéricardique combiné comprenant des diaphragmotomies en forme de T et circulaires, combinées à des péricardotomies longitudinales et circulaires. Nous avons utilisé quatre corps préservés avec la méthode Thiel pour réaliser les simulations chirurgicales. La néphrectomie radicale avec thrombectomie a été réalisée par deux experts de manière indépendante. Quatre approches chirurgicales de la VCI supradiaphragmatique ont été réalisées consécutivement. Nous avons utilisé des simulateurs de TT de différents diamètres et densités pour étudier la palpation de l'apex du TT et son déplacement. La faisabilité et la sécurité de chaque accès et de chaque procédure chirurgicale ont été évaluées à l'aide du test du Chi carré, avec correction des comparaisons multiples (Bonferroni). Notre travail a confirmé la faisabilité et la sécurité des approches transdiaphragmatiques. Les accès transpéricardiques sont préférables dans les cas où les TT sont plus élevés. Ils constituent une alternative adéquate à la chirurgie conventionnelle en cas de TT flottant supradiaphragmatique, jusqu’à l’atrium droit. / Despite significant progress in early diagnosis, there has been a clear trend in recent years towards an increasing number of renal cell carcinoma (RCC) patients with a specific complication in the form of a tumor thrombus (TT) extending along the lumen of the inferior vena cava (IVC) above the level of the diaphragm into the right atrium. The only effective treatment for RCC with TT remains surgery. Conventional surgery includes radical nephrectomy with thrombectomy, requiring cardiopulmonary bypass techniques and cessation of blood flow, which always involves serious complications. To avoid them, various options for surgical access to the supradiaphragmatic part of the IVC and the right atrium have been proposed exclusively from the abdominal side, using various options of diaphragmotomy and pericardotomy with isolation of the IVC in the pericardial cavity. One of the most important issues in the surgical treatment of RCC with supradiaphragmatic TT is the control of the distal end of the TT. This step depends largely on the access chosen. In this work, to optimize surgical techniques for patients with supradiaphragmatic TT, we compared the feasibility and safety of different transdiaphragmatic surgical accesses. We also proposed a combined transdiaphragmatic transpericardial access including T-shaped and circular diaphragmotomies combined with longitudinal and circular pericardotomies. We used four bodies preserved with the Thiel method to perform the surgical simulations. Radical nephrectomy with thrombectomy was performed by two experts independently. Four supradiaphragmatic ICV surgical approaches were performed consecutively. We used TT simulators of different diameters and densities to study palpation of the TT apex and its displacement. The feasibility and safety of each access and surgical procedure were evaluated using the Chi-square test with correction for multiple comparisons (Bonferroni). Our work confirmed the feasibility and safety of transdiaphragmatic approaches. Transpericardial accesses are preferable in cases with higher TT. They are an adequate alternative to conventional surgery in cases of supradiaphragmatic floating TT, up to the right atrium.

Three clinical investigations together with a combined editorial and review of the cardiovascular physiology of spinal anaesthesia in normal and preeclamptic pregnancy form the basis of a thesis to be submitted for the degree of Doctor of Medicine at the University of St Andrews. First, the longstanding consensus that spinal anaesthesia could cause severe hypotension in severe preeclampsia was examined using three approaches. The doses of ephedrine required to maintain systolic blood pressure above predetermined limits were first compared in spinal versus epidural anaesthesia. The doses of ephedrine required were then similarly studied during spinal anaesthesia in preeclamptic versus normal control subjects. The principal outcome of these studies, that preeclamptic patients were resistant to hypotension after a spinal anaesthetic, was then further investigated by studying pulse transit time (PTT) changes in normal versus preeclamptic pregnancy. PTT was explored both as beat-to-beat monitor of cardiovascular function and also as an indicator of changes in arterial stiffness. The cardiovascular physiology of obstetric spinal anaesthesia was then reviewed in the light of the three clinical investigations, developments in reproductive vascular biology and the regulation of venous capacitance. It is argued that the theory of a role for vena caval compression as the single cause of spinal anaesthetic induced hypotension in obstetrics should be revised.

<p>Uvod: Pacijenti na hemodijalizi (HD) imaju visoku stopu ukupnog i kardiovaskularnog morbiditeta i mortaliteta. Preko 80% bolesnika na HD ima neki tip kardiovaskularne bolesti. Hipervolemija značajno doprinosi njihovom nastanku, dovodeći do hipertenzije, hipertrofije miokarda leve komore, srčane insuficijencije i nastanka plućnog edema. Procena stanja volemije kod pacijenata na HD najče&scaron;će se vr&scaron;i kliničkim pregledom, uprkos nezadovoljavajućoj specifičnosti i senzitivnosti. Hipervolemija je prisutna kod određenog broja pacijenata, uprkos normotenziji, odsustvu edema i urednom auskultatornom nalazu na plućima. Različite metode se koriste za procenu stanja volemije, svaka sa određenim manama. Upotreba analize bioelektrične impedanse zahteva skupu opremu i potro&scaron;ni materijal, vrednosti B-tipa natriuretskog peptida (BNP) i njegovog N terminalnog propeptida (NT-proBNP) zavise i od stanja volemije i od srčane funkcije, kao i od tipa dijalizne membrane. Ehokardiografija (EHO) i ultrazvuk donje &scaron;uplje vene (UZ ICV) sa određivanjem dijametara u inspirijumu i ekspirijumu (IVCDi i IVCDe) zahteva posebno obučen kadar. Ultrazvuk pluća (UZ pluća) je jednostavna, brza i jeftina metoda za detekciju ekstravaskularne plućne tečnosti (EVLW). EVLW predstavlja onu količinu tečnosti koja se nalazi u plućnom intersticijumu. UZ pluća detektuje EVLW kao UZ artefakte zvane &bdquo;B linije&ldquo;. Količina EVLW zavisna je od pritiska punjenja leve komore i povećava se u stanjima hipervolemije, &scaron;to se na UZ pluća manifestuje kao veći broj detektovanih &bdquo;B linija&ldquo;. Zbir svih &bdquo;B linija&ldquo; detektovanih na definisanim mestima na grudnom ko&scaron;u naziva se &bdquo;skor B linija&ldquo; (BLS) i koristi se za kvantifikaciju EVLW pomoću UZ pluća. Cilj: Uporediti adekvatnost i efikasnost UZ pluća u proceni stanja volemije kod pacijenata na HD u odnosu na standardne tehnike UZ donje &scaron;uplje vene, EHO i BNP-a. Proceniti mogućnost pojednostavljenja protokola UZ pregleda pluća redukcijom broja analiziranih plućnih polja. Materijal i metode: Istraživanje je sprovedeno kao studija preseka od aprila 2016. do juna 2017. godine na 83 pacijenta koji su se nalazili na hroničnom programu HD u Službi za HD Odeljenja za internu medicinu Op&scaron;te bolnice Kikinda. Ispitanicima je prvog dana HD u nedelji neposredno pre HD urađen UZ pluća, UZ IVC, EHO, i uzorkovanje krvi za određivnje vrednosti BNP-a. Potom su pacijenti dijalizirani prema svojim utvrđenim HD protokolima. Neposredno nakon HD ponovljeni su UZ pluća, UZ IVC, EHO, a uzorkovanje krvi za BNP je ponovljeno pre započinjanja sledeće HD u nedelji, da bi se izbegao neposredni postdijalizni skok BNP-a. Za poređenje varijabli kori&scaron;ćeni su T test parova odnosno Vilkoksonov test, a za ispitivanje korelacije Pirsonov odnosno Spirmanov test, u zavisnosti od distribucije varijabli. Razlike između grupa ispitanika ispitivane su pomoću jednofaktorske analize varijanse (ANOVA) za kontinuirane varijable, a za kategorijske je kori&scaron;ćena analiza kontingencijskih tabela. Analiza glavnih komponenata (PCA) je kori&scaron;ćena za procenu mogućnosti redukcije broja ispitivanih plućnih polja. Rezultati: Utvrđena je signifikantna razlika između predijaliznih (pre HD) srednjih vrednosti BLS-a (18,85) i postdijaliznih (post HD) srednjih vrednosti BLS-a (7,30); između srednjih vrednosti BNP-a pre HD (894,89 pg/ml) i post HD (487,74 pg/ml); između srednjih vrednosti IVCDe pre HD (10,45 mm) i post HD (7,85 mm); između srednjih vrednosti IVCDi pre HD (7,20 mm) i post HD (4,41 mm); između srednjih vrednosti indeksa kolapsibilnosti IVC pre HD (32%) i post HD (45%). Utvrđene su i signifikantne razlike između srednjih vrednosti sledećih EHO parametara: dijametar leve pretkomore pre HD (3,78 cm) i post HD (3,53 cm), dijametra leve komore u dijastoli pre HD (5,21 cm) i post HD (4,96 cm), dijametra leve komore u sistoli pre HD (3,69 cm) i post HD (3,43 cm) i zapremine leve pretkomore u sistoli pre HD (60,54 ml) i post HD (52,36 ml). Sve razlike su bile signifikantne na nivou p&lt;0,0001. Dokazana je signifikantna pozitivna korelacija između BLS-a pre HD i BNP-a pre HD (&rho;=0,49, p&lt;0,01) i BNP-a post HD (0,43, p&lt;0,01); BLS-a pre HD i IVCDe pre HD (&rho;=0,29, p&lt;0,01), IVCDi pre HD (&rho;=0,30, p&lt;0,05) i IVCDi post HD (&rho;=0,23, p&lt;0,05) kao i između BLS-a post HD i BNP-a pre HD (&rho;=0,44, p&lt;0,01) i BNP-a post HD (&rho;=0,42, p&lt;0,01), između BLS-a post HD i IVCDe pre HD (&rho;=0,29, p&lt;0,05) IVCDi pre HD (&rho;=0,33, p&lt;0,05) i IVCDi post HD (&rho;=0,23, p&lt;0,05). Utvrđeno je da su bolesnici sa vi&scaron;im BLS-om imali niže vrednosti hemoglobina (p=0,006) i vi&scaron;e vrednosti visoko senzitivnog troponina T (p=0,02), kao i veće dijametre leve komore u sistoli (p=0,04). Pomoću PCA utvrđeno je da je moguća redukcija broja ispitivanih plućnih polja na 4 do 12 plućnih polja, koja bi bila odgovorna za 75,38% odnosno 84,51% varijabilnosti BLS-a. Zaključak: UZ pluća može adekvatno i efikasno da proceni stanje volemije i može se koristiti za ovu svrhu kod pacijenata na hroničnom programu HD. UZ pluća je brz, jednostavan i jeftin pregled koji se može izvoditi u bolesničkoj postelji i koji daje pouzdan podatak o bolesnikovom statusu volemije u realnom vremenu. UZ pluća bez većih te&scaron;koća mogao uključiti u kliničke protokole u svim centrima sa dostupnom opremom. Postoji mogućnost redukcije broja ispitivanih plućnih polja i time pojednostavljenja samog UZ pregleda pluća. UZ pluća može koristiti u proceni srčane funkcije kod pacijenata na HD. Pacijenti koji su procenjeni kao hipervolemični pomoću UZ pluća imaju povećan kardiovaskularni rizik, kao i pacijenti procenjeni kao hipervolemični pomoću vrednosti BNP-a i dijametra D&Scaron;V.</p> / <p>Introduction: Patients on hemodialysis (HD) have a high general morbidity and all-cause mortality, as well as high cardiovascular morbidity and mortality. More than 80% of patients on HD have some cardiovascular disease. Hypervolemia plays a significant role here, contributing to hypertension, left ventricular hypertrophy, heart failure and pulmonary edema. Fluid status assessment in HD is still mostly clinical, despite having low specificity and sensitivity. A number of patients remain hypervolume, despite being normotensive, without edema or bibasilar crackles on lung auscultation. Different methods are used for volume status assessment in HD setting, no method without its flaws. Bioelectric impedance analysis requires expensive equipment and supplies. B type natriuretic peptide (BNP) values, and those of its terminal propeptide (NT-proBNP) depend on volume status, cardiac function as well as type of dialysis membrane used. Echocardiography (ECHO) and ultrasonography of inferior vena cava (IVC US) with measurements of its diameters in inspirum and expirium (IVCDi and IVCDe) require trained medical personnel. Lung ultrasound (LUS) is a simple, fast and inexpensive method for detection of extravascular lung water (EVLW), which is the water contained in the lung interstitium. LUS detects EVLW as ultrasonographic artefacts called &bdquo;B lines&ldquo;. EVLW is dependent on left ventricular filling pressures and is increased in volume overload, manifesting as more &bdquo;B lines&ldquo; on LUS. The sum of all &bdquo;B lines&ldquo; detected on predetermined places on the chest is called &bdquo;B line score&ldquo; (BLS) and is used to quantify EVLW using LUS. Goal: Compare the adequacy and efficacy of LUS in assessment of volume status in patients on HD to other methods (IVC US, ECHO, BNP). Assess the possibility of simplifying LUS by reducing the number of examined lung fields. Materials and methods: A cross-section study was performed from April 2016 to June 2017. on 83 dialysis patients in Dialysis unit of Internal medicine department of General hospital Kikinda. LUS, ECHO, IVC US and blood sampling for BNP were performed on the first dialysis day of the week, just prior to HD. Patients were then dialyzed according to their dialysis protocols. After HD all tests were repeated, except blood sampling for BNP, which was sampled just prior to the next HD session in order to avoid elevated BNP values after HD. Variables were compared using double sample T test or Wilcoxon test. Correlation was assessed using Pearson&rsquo;s or Spearman&rsquo;s test, depending on variable distribution. Differences between groups were tested using one-way analysis of variance for continuous variables and contingency tables for categorical variables. Principal component analysis (PCA) was used to assess the possibility of lung field reduction. Results: There was a significant difference between BLS predialysis (pre HD) (mean 18,85) and BLS postdialysis (post HD) (mean 7,30); between IVCDe pre HD (mean 10,45 mm) and IVCDe post HD (mean 7,85 mm); between IVCDi pre HD (mean 7,20 mm) and IVCDi post HD (mean 4,41 mm); between CCI pre HD (mean 32%) and CCI post HD (mean 45%), between BNP pre HD (mean 894,89 pg/ml) and BNP post HD (mean 487,74 pg/ml). There was also a significant difference between the following ECHO parameters: left atrial diameter pre HD (mean 3,78 cm) and post HD (mean 3,53 cm), left ventricular internal diameter in diastole pre HD (mean 5,21 cm) and post HD (mean 4,96 cm) and left ventricular internal diameter in sistole pre HD (mean 3,69 cm) and post HD (mean 3,43 cm), left atrial volume in sistole pre HD (mean 60,54 ml) and post HD (mean 52,36 ml). All differences were significant at a level of p&lt;0,0001. There was a significant positive correlation between BLS pre HD and BNP pre HD (&rho;=0,49, p&lt;0,01) and BNP post HD (&rho;=0,43, p&lt;0,01); BLS pre HD and IVCDe pre HD (&rho;=0,29, p&lt;0,01) IVCDi pre HD (&rho;=0,30, p&lt;0,05) and IVCDi post HD (&rho;=0,23, p&lt;0,05); between BLS post HD and BNP pre HD (&rho;=0,44, p&lt;0,01) and BNP post HD (&rho;=0,42, p&lt;0,01); between BLS post HD and IVCDe pre HD (&rho;=0,29, p&lt;0,05), IVCDi pre HD (&rho;=0,33, p&lt;0,05) and IVCDi post HD (&rho;=0,23, p&lt;0,05). Subjects with higher BLS had lower hemoglobin levels (p=0,006), higher troponin T levels (p=0,02) and greater left ventricular internal dimensions in sistole (p=0,04). PCA showed that there is a possibility of lung field reduction to 12 lung fields and even down to 4 lung fields, which would account for 84,51% or 75,38% of BLS variability. Conclusion: LUS can be used to adequately and effectively assess volume status in patients on HD. LUS is simple, fast and inexpensive exam with bedside capability, which gives accurate volume status data in real time. The exam can be implemented into dialysis unit protocols without difficulty. There is a possibility of simplifying LUS by reducing the number of examined lung fields. LUS can be used in assessment of cardiac function in patients on HD. Patients rated as hypervolemic by LUS have increased cardiovascular risk, as well as patients rated as hypervolemic by BNP levels or IVC diameters.</p>

O transplante hepático com a técnica convencional envolve a ressecção da veia cava inferior retrohepática como parte da hepatectomia do receptor e conseqüente clampeamento da mesma acima e abaixo do fígado, bem como o clampeamento da veia porta durante a fase anepática. Este procedimento pode se caracterizar por alterações hemodinâmicas importantes, disfunção renal e maior sangramento em áreas de dissecção submetidas a um regime de maior pressão. Pacientes idosos, previamente instáveis do ponto de vista hemodinâmico ou muito graves, gealmente, não toleram esta situação. Para evitar estes distúrbios, um \"bypass\" venovenoso, é habitualmente utilizado, permitindo com que o sangue da veia porta e da veia cava inferior retorne à circulação sistêmica através da veia axilar. O \"bypass\" venovenoso, foi adotado por muitos centros transplantadores como procedimento de rotina, enquanto outros empregavam este apenas quando o clampeamento da veia cava inferior determinasse grave alteração hemodinâmica, buscando assim, redução do custo, do tempo de operação e das complicações em função do uso \"bypass\", tais como: hipotermia, coagulopatia e fenômenos tromboembólicos. Outra alternativa técnica, que consiste na preservação da veia cava inferior durante a hepatectomia foi descrita com o intuito de preservar o fluxo na veia cava inferior durante a fase anepática. Além disto, uma anastomose porto-cava temporária pode ser confeccionada para evitar o clampeamento da veia porta e conseqüente congestão esplâncnica. O objetivo deste estudo foi comparar os resultados imediatos do transplante hepático com preservação da veia cava inferior e anastomose porto-cava temporária, ou com o uso do \"bypass\" venovenoso. De outubro de 1999 a outubro de 2001, 104 pacientes submetidos ao transplante hepático foram analisados retrospectivamente. O \"bypass\" venovenoso foi utilizado em 50 pacientes e a técnica de \"piggy back\" em 54. Ambos os grupos foram comparáveis em termos de idade, sexo, diagnóstico e grau de função hepática pré-operatória. Nosso estudo demonstrou não haver diferença entre as duas técnicas em relação à duração da hepatectomia, à duração da operação e à necessidade de transfusão de hemoderivados. Observou-se uma fase anepática mais breve e um menor tempo de permanência na unidade de terapia intensiva no período pós operatório dos pacientes submetidos à técnica que reserva a veia cava inferior, além disto o estudo aponta para uma tendência à redução no tempo de internação, no índice de insuficiência renal pós-operatória e para um melhor funcionamento do enxerto quando os fluxos da veia cava inferior e da veia porta são preservados. / The liver transplant with conventional technique involves the resection of the retrohepatic inferior vena cava as part of the recipient hepatectomy and consequent clamping of the same above and below the liver, as well as the clamping of the portal vein during the anhepatic phase. This procedure can be characterized by critical hemodynamic alterations, renal disfunction and greater bleeding in dissection areas submitted to higher pressure conditions. Elderly patients, previously unstable on a hemodynamic point of view or in very serious conditions, usually do not tolerate this situation. In order to avoid these disturbances, a venovenous bypass is commonly applied, allowing blood from the portal vein and inferior vena cava to return to the systemic circulation through the axilar vein. The venovenous bypass has been adopted by many transplant centers as a routine procedure, while others have applied this procedure only when clamping of the inferior vena cava determines a serious hemodynamic alteration, eeking, in this way, cost cutting, reduction of operation time and complications caused by usage of the bypass, such as: hypothermy, coagulopathy and romboembolic phenomenae. Another technical alternative, which consists of preservation of the inferior vena cava during the hepatectomy was described focusing preservation of the inferior vena cava flow during the anhepatic phase. Besides, a temporary portocaval shunt can be made to avoid clamping of the portal vein and consequently splanchnic congestion. The objective of this study was compare the immediate results of the liver transplantation with inferior vena cava preservation and temporary portocaval shunt or using the venovenous bypass. From October 1999 to October 2001, 104 patients submitted to an liver transplantat were analyzed retrospectively. The venovenous bypass was applied in 50 patients and the \"piggy back\" technique in 54. Both groups were comparable in terms of age, gender, diagnosis and preoperative hepatic conditions. Our study has demonstrated that there was no difference between the two techniques in relation to the hepatectomy and operation time and the need of hemoderivate transfusion. As a result, a shorter anhepatic phase was observed, as well as a shorter stay in intensive care unit during the postoperative period, in relation to patients submitted to the technique that preserves the inferior vena cava. Additionally, the study points out a trend towards reduction of hospital stay, postoperative renal insufficiency, and a better graft function when the inferior cava and portal veins are preserved.

O transplante hepático com a técnica convencional envolve a ressecção da veia cava inferior retrohepática como parte da hepatectomia do receptor e conseqüente clampeamento da mesma acima e abaixo do fígado, bem como o clampeamento da veia porta durante a fase anepática. Este procedimento pode se caracterizar por alterações hemodinâmicas importantes, disfunção renal e maior sangramento em áreas de dissecção submetidas a um regime de maior pressão. Pacientes idosos, previamente instáveis do ponto de vista hemodinâmico ou muito graves, gealmente, não toleram esta situação. Para evitar estes distúrbios, um \"bypass\" venovenoso, é habitualmente utilizado, permitindo com que o sangue da veia porta e da veia cava inferior retorne à circulação sistêmica através da veia axilar. O \"bypass\" venovenoso, foi adotado por muitos centros transplantadores como procedimento de rotina, enquanto outros empregavam este apenas quando o clampeamento da veia cava inferior determinasse grave alteração hemodinâmica, buscando assim, redução do custo, do tempo de operação e das complicações em função do uso \"bypass\", tais como: hipotermia, coagulopatia e fenômenos tromboembólicos. Outra alternativa técnica, que consiste na preservação da veia cava inferior durante a hepatectomia foi descrita com o intuito de preservar o fluxo na veia cava inferior durante a fase anepática. Além disto, uma anastomose porto-cava temporária pode ser confeccionada para evitar o clampeamento da veia porta e conseqüente congestão esplâncnica. O objetivo deste estudo foi comparar os resultados imediatos do transplante hepático com preservação da veia cava inferior e anastomose porto-cava temporária, ou com o uso do \"bypass\" venovenoso. De outubro de 1999 a outubro de 2001, 104 pacientes submetidos ao transplante hepático foram analisados retrospectivamente. O \"bypass\" venovenoso foi utilizado em 50 pacientes e a técnica de \"piggy back\" em 54. Ambos os grupos foram comparáveis em termos de idade, sexo, diagnóstico e grau de função hepática pré-operatória. Nosso estudo demonstrou não haver diferença entre as duas técnicas em relação à duração da hepatectomia, à duração da operação e à necessidade de transfusão de hemoderivados. Observou-se uma fase anepática mais breve e um menor tempo de permanência na unidade de terapia intensiva no período pós operatório dos pacientes submetidos à técnica que reserva a veia cava inferior, além disto o estudo aponta para uma tendência à redução no tempo de internação, no índice de insuficiência renal pós-operatória e para um melhor funcionamento do enxerto quando os fluxos da veia cava inferior e da veia porta são preservados. / The liver transplant with conventional technique involves the resection of the retrohepatic inferior vena cava as part of the recipient hepatectomy and consequent clamping of the same above and below the liver, as well as the clamping of the portal vein during the anhepatic phase. This procedure can be characterized by critical hemodynamic alterations, renal disfunction and greater bleeding in dissection areas submitted to higher pressure conditions. Elderly patients, previously unstable on a hemodynamic point of view or in very serious conditions, usually do not tolerate this situation. In order to avoid these disturbances, a venovenous bypass is commonly applied, allowing blood from the portal vein and inferior vena cava to return to the systemic circulation through the axilar vein. The venovenous bypass has been adopted by many transplant centers as a routine procedure, while others have applied this procedure only when clamping of the inferior vena cava determines a serious hemodynamic alteration, eeking, in this way, cost cutting, reduction of operation time and complications caused by usage of the bypass, such as: hypothermy, coagulopathy and romboembolic phenomenae. Another technical alternative, which consists of preservation of the inferior vena cava during the hepatectomy was described focusing preservation of the inferior vena cava flow during the anhepatic phase. Besides, a temporary portocaval shunt can be made to avoid clamping of the portal vein and consequently splanchnic congestion. The objective of this study was compare the immediate results of the liver transplantation with inferior vena cava preservation and temporary portocaval shunt or using the venovenous bypass. From October 1999 to October 2001, 104 patients submitted to an liver transplantat were analyzed retrospectively. The venovenous bypass was applied in 50 patients and the \"piggy back\" technique in 54. Both groups were comparable in terms of age, gender, diagnosis and preoperative hepatic conditions. Our study has demonstrated that there was no difference between the two techniques in relation to the hepatectomy and operation time and the need of hemoderivate transfusion. As a result, a shorter anhepatic phase was observed, as well as a shorter stay in intensive care unit during the postoperative period, in relation to patients submitted to the technique that preserves the inferior vena cava. Additionally, the study points out a trend towards reduction of hospital stay, postoperative renal insufficiency, and a better graft function when the inferior cava and portal veins are preserved.

Au sein des unités de médecine d'urgence, l'état de choc est une condition courante et par le fait même, une cause majeure de mortalité en Amérique du nord. Il est donc essentiel d'en rechercher rapidement les causes. Dans cette recherche, l'évaluation clinique, l'examen des signes vitaux et les tests de laboratoire se révèlent souvent imprécis car ils ne permettent pas d'évaluer de façon optimale le statut hémodynamique des patients instables. Or, le risque d'une évaluation insuffisante de l’état hémodynamique conduit à l'instauration d'un traitement inapproprié dont la conséquence peut être fatale. Une simple surestimation du besoin de remplissage vasculaire peut entraîner des complications telles que l'œdème pulmonaire et inversement, la sous-estimation peut avoir pour conséquence une hypovolémie persistante avec une hypoperfusion ou un état de choc non reconnu susceptible de générer une insuffisance des organes cibles. Actuellement, pour évaluer le statut hémodynamique, les méthodes les plus utilisées sont la pression veineuse centrale (PVC), les cathéters de Swan-Ganz et l’échocardiographie transoesophagienne. Bien que déjà difficiles à réaliser à l’urgence, toutes ces méthodes sont invasives et conservent un potentiel élevé de morbidité. Il existe toutefois des méthodes alternatives valides qui permettent d'obtenir une estimation non invasive de la pression moyenne de l'oreillette droite, entre autre l’échographie sous-costale avec les mesures échographiques de la collapsibilité de la veine cave inférieure (VCI) et les mesures de Doppler échographiques sur la veine hépatique (VH). Il convient cependant de noter que la mesure de la collapsibilité de la VCI n’a pas réussi à devenir un standard d’évaluation de la volémie parce qu’elle reste sujette à plusieurs facteurs confondants.   La mesure du flot de la VH, quant à elle, semble être une option plus intéressante pour mieux évaluer la pression de remplissage de l’oreillette droite. En effet, l'échographie Doppler de la veine hépatique reste donc un instrument potentiellement prometteur qui peut bien refléter les pressions de l’OD et donc de la pression veineuse centrale. Il importe de souligner que pour le patient instable, chaque minute est précieuse et qu’un gain de temps inestimable contribue à éliminer les facteurs susceptibles de compromettre le pronostic vital. L’objectif principal de notre étude, étant la mesure du temps nécessaire pour l’acquisition d’images ; nous avons comparé la durée de l'acquisition d'images entre l'échographie de la VCI et le Doppler de la VH chez des sujets sains. Le temps moyen d'acquisition d'images de la VCI était de 89,1 secondes et de 117,8 pour la VH. La différence de la moyenne de temps était de 28,6 secondes (IC95% -73,2 · +15,8 ; t=1.33, 24 dl ; p=0.196). La différence de délai pour le temps d’acquisition d’images était inférieure à 30 secondes. En pratique, nous pensons que cette différence peut être considérée comme cliniquement acceptable pour une prise de décision rapide. En ce qui concerne le taux d’échec entre les deux techniques, nous n’avons pas trouvé de différence significative : 1 échec pour la VCI et 5 échecs pour la VH avec une différence de 13% (0.133), p=0.09 ; alors que le taux de réussite est le même, soit 25 pour chacune. L’évaluation de la veine hépatique par échographie était faisable, simple et rapide dans la majorité des volontaires sélectionnés dans notre étude. Mots-clés : échographie Doppler, veine cave inférieure, veines hépatiques, état de choc, statut hémodynamique. / Shock is a common condition and a major cause of death in emergency units. Clinical evaluation, vital signs and laboratory tests can lack specificity to identify the cause of shock and do not allow an optimal evaluation of the hemodynamic status of unstable patients. A poor evaluation of the hemodynamic state could lead to inappropriate treatment and the consequence may be fatal. Overestimation of the need for vascular filling can lead to complications such as pulmonary edema; while underestimation may give rise to persistent hypovolemia with hypoperfusion or unrecognized shock resulting in multi-organ failure. The current methods used to assess hemodynamic status are central venous pressure, Swan-Ganz catheters, and trans-esophageal echocardiography. Although already difficult to perform in the emergency department, all of these methods are invasive and retain a high potential for morbidity. However, there are valid alternative methods for obtaining a non-invasive estimate of the average pressure of the right atrium, including subxiphoid ultrasound with measurements of the inferior vena cava (IVC) collapsibility and ultrasound Doppler measurements of the hepatic veins (HV). However, the measurement of the collapsibility of the IVC is subject to several confounding factors and has failed to become a standard of care for evaluating patients’ volemic status. Measuring the flow of the hepatic vein, on the other hand, seems to be a more interesting option for better assessing the filling pressure of the right atrium. Indeed, the Doppler ultrasound of hepatic veins remains a potentially promising instrument that may well reflect the pressures of the right atrium and thus of the central venous pressure. It is important to emphasize that for the unstable patient, every minute is precious and that saving time contributes to eliminate factors likely to compromise the vital prognosis.   The main objective of our study is to measure the time it takes to acquire images. We compared the duration of image acquisition between IVC ultrasound and HV Doppler in healthy volunteers. The average image acquisition time for the IVC and HV was 89.1 and 117.8 seconds respectively. The difference in mean time was 28.6 seconds (95% CI -73.2 · + 15.8, t = 1.33, 24 dL, p = 0.196). The difference for image acquisition time was less than 30 seconds. In practice, we believe that this difference can be considered clinically acceptable for rapid decision-making. Regarding the failure rate between the two techniques, we did not find any significant difference: 1 failure for IVC and 5 failures for HV with a difference of 13% (0.133), p = 0.09; while the success rate is the same, 25 for each. The evaluation of the hepatic vein by ultrasonography was feasible, simple and fast in the majority of volunteers selected in our study. Key words: Doppler ultrasonography, inferior vena cava, hepatic veins, shock, hemodynamic status