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OBJECTIVES: To evaluate the effect of the intraoperative use of hydroxyethyl starch on the need for blood products in the perioperative period of oncologic surgery. The secondary end-points included the need for other blood products, the clotting profile, the intensive care unit mortality and length of stay. METHODS: Retrospective observational analysis in a tertiary oncologic ICU in Brazil including 894 patients submitted to oncologic surgery for a two-year period from September 2007. Patients were grouped according to whether hydroxyethyl starch was used during surgery (hydroxyethyl starch and No-hydroxyethyl starch groups) and compared using a propensity score analysis. A total of 385 propensity-matched patients remained in the analysis (97 in the No-hydroxyethyl starch group and 288 in the hydroxyethyl starch group). RESULTS: A higher percentage of patients in the hydroxyethyl starch group required red blood cell transfusion during surgery (26% vs. 14%; p = 0.016) and in the first 24 hours after surgery (5% vs. 0%; p = 0.015) but not in the 24- to 48-hour period after the procedure. There was no difference regarding the transfusion of other blood products, intensive care unit mortality or length of stay. CONCLUSION: Hydroxyethyl starch use in the intraoperative period of major oncologic surgery is associated with an increase in red blood cell transfusions. There are no differences in the need for other blood products, intensive care unit length of stay or mortality.

OBJECTIVES: Hemodynamic support is aimed at providing adequate O2 delivery to the tissues; most interventions target O2 delivery increase. Mixed venous O2 saturation is a frequently used parameter to evaluate the adequacy of O2 delivery. METHODS: We describe a mathematical model to compare the effects of increasing O2 delivery on venous oxygen saturation through increases in the inspired O2 fraction versus increases in cardiac output. The model was created based on the lungs, which were divided into shunted and non-shunted areas, and on seven peripheral compartments, each with normal values of perfusion, optimal oxygen consumption, and critical O2 extraction rate. O2 delivery was increased by changing the inspired fraction of oxygen from 0.21 to 1.0 in steps of 0.1 under conditions of low (2.0 L.min-1) or normal (6.5 L.min-1) cardiac output. The same O2 delivery values were also obtained by maintaining a fixed O2 inspired fraction value of 0.21 while changing cardiac output. RESULTS: Venous oxygen saturation was higher when produced through increases in inspired O2 fraction versus increases in cardiac output, even at the same O2 delivery and consumption values. Specifically, at high inspired O2 fractions, the measured O2 saturation values failed to detect conditions of low oxygen supply. CONCLUSIONS: The mode of O2 delivery optimization, specifically increases in the fraction of inspired oxygen versus increases in cardiac output, can compromise the capability of the "venous O2 saturation" parameter to measure the adequacy of oxygen supply. Consequently, venous saturation at high inspired O2 fractions should be interpreted with caution.

Sepsis is a major cause of mortality and morbidity in intensive care units. Organ dysfunction is triggered by inflammatory insults and tissue hypoperfusion. The brain plays a pivotal role in sepsis, acting as both a mediator of the immune response and a target for the pathologic process. The measurement of brain dysfunction is difficult because there are no specific biomarkers of neuronal injury, and bedside evaluation of cognitive performance is difficult in an intensive care unit. Although sepsis-associated encephalopathy was described decades ago, it has only recently been subjected to scientific scrutiny and is not yet completely understood. The pathophysiology of sepsis-associated encephalopathy involves direct cellular damage to the brain, mitochondrial and endothelial dysfunction and disturbances in neurotransmission. This review describes the most recent findings in the pathophysiology, diagnosis, and management of sepsis-associated encephalopathy and focuses on its many presentations.

Uncompensated heart failure (UHF) is a leading cause of hospitalization. The available drugs to treat acute UHF include inotropes, diuretics and vasodilators. In recent years, hypertonic saline (HTS) has emerged as a new potential therapy for refractory heart failure, usually in association with high doses of diuretics. However, there have been no reports describing the use of HTS as a first-line treatment for UHF. Here, we report a case in which a 10% NaCl solution was used as the primary therapy for a patient with UHF. Almost immediately, hypertonic saline was able to restore the patient's hemodynamic profile and to eliminate Cheyne-Stokes respiration (CSR), which is associated with a low cardiac output state.