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CONTEXT: Heart failure in Brazil is a major public health problem and, even with advances in treatment, it still presents high morbidity and mortality. As a treatment option, mechanical circulatory assist devices (MCADs) have greatly increased in importance over the last decade. CASE REPORT: This report concerns a case of refractory cardiogenic shock due to acute myocarditis in a 35-year-old puerperal female patient who presented with retrosternal pain, fatigue and dyspnea. At the hospital, she was diagnosed with myocarditis. There was no improvement in perfusion even after receiving dobutamine, intra-aortic balloon passage (IAB) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, it was decided to implant a MCAD (CentriMag). During hospitalization, recovery from the bi-ventricular dysfunction was achieved. The CentriMag device was removed 10 days after it had been implanted, and the patient was discharged after another 8 days. The myocarditis was proven to be due to the Coxsackie virus. CONCLUSIONS: The decision to implant a MCAD should be individualized, as patient profiles do not always match the indications in the guidelines and protocols. In this study, clinical discussion of the case among the medical and multi-professional teams was essential in order to be able to successfully reverse the patient’s severe clinical condition without sequelae, through using a CentriMag implant.

Objectives To investigate acute stress response in residents playing nurse and physician roles during emergency simulations. Methods Sixteen second-year internal medicine residents participated in teams of four (two playing physician roles and two playing nurse roles). Stress markers were assessed in 24 simulations at baseline (T1) and immediately after the scenario (T2), using heart rate, systolic and diastolic blood pressure, salivary α-amylase, salivary cortisol and salivary interleukin-1β. The State-Trait Anxiety Inventory was applied at T2. Continuous data were summarized for the median (1st-3rd interquartile ranges), and the Mann-Whitney U Test was used to compare the groups. Results The percent variations of the stress markers in the physician and nurse roles, respectively, were the following: heart rate: 70.5% (46.0-136.5) versus 53.0% (29.5-117.0), U=89.00, p=0.35; systolic blood pressure: 3.0% (0.0-10.0) versus 2.0% (-2.0-9.0), U=59.50, p=0.46; diastolic blood pressure: 5.5% (0.0-13.5) versus 0.0% (0.0-11.5), U=91.50, p=0.27; α-amylase: -5.35% (-62.70-73.90) versus 42.3% (12.4-133.8), U=23.00, p=0.08; cortisol: 35.3% (22.2-83.5) versus 42.3% (12.4-133.8), U=64.00, p=0.08); and interleukin-1β: 54.4% (21.9-109.3) versus 112.55% (29.7-263.3), U= 24.00, p=0.277. For the physician and nurse roles, respectively, the average heart rate was 101.5 (92.0-104.0) versus 91.0 (83.0-99.5) beats per minute, U=96.50, p=0.160; and the state anxiety inventory score was 44.0 (40.0-50.0) versus 42.0 (37.50-48.0) points, U= 89.50, p=0.319. Conclusions Different roles during emergency simulations evoked similar participants’ engagement, as indicated by acute stress levels. Role-play strategies can provide high psychological fidelity for simulation-based training, and these results reinforce the potential of role-play methodologies in medical education.

Purpose Medical simulation is fast becoming a standard of health care training throughout undergraduate, postgraduate and continuing medical education. Our aim was to evaluate if simulated scenarios have a high psychological fidelity and induce stress levels similarly to real emergency medical situations. Materials and Methods Medical residents had their stress levels measured during emergency care (real-life and simulation) in baseline (T1) and immediately post-emergencies (T2). Parameters measuring acute stress were: heart rate, systolic and diastolic blood pressure, salivary α -amylase, salivary interleukin-1 β , and State-Trait Anxiety Inventory score. Results Twenty-eight internal medicine residents participated in 32 emergency situations (16 real-life and 16 simulated emergencies). In the real-life group, all parameters increased significantly ( P β increased significantly after emergencies. The comparison between groups demonstrates that acute stress response (T2 – T1) and State-Trait Anxiety Inventory score (in T2) did not differ between groups. Conclusions Acute stress response did not differ between both groups. Our results indicate that emergency medicine simulation may create a high psychological fidelity environment similarly to what is observed in a real emergency room.

Providing care for simulated emergency patients may induce considerable acute stress in physicians. However, the acute stress provoked in a real-life emergency room (ER) is not well known. Our aim was to assess acute stress responses in residents during real emergency care and investigate the related personal and situational factors. A cross-sectional observational study was carried out at an emergency department of a tertiary teaching hospital. All second-year internal medicine residents were invited to voluntarily participate in this study. Acute stress markers were assessed at baseline (T1), before residents started their ER shift, and immediately after an emergency situation (T2), using heart rate, systolic, and diastolic blood pressure, salivary α-amylase activity, salivary interleukin-1 β, and the State-Trait Anxiety Inventory (STAI-s and STAI-t). Twenty-four residents were assessed during 40 emergency situations. All stress markers presented a statistically significant increase between T1 and T2. IL-1 β presented the highest percent increase (141.0%, p .001), followed by AA (99.0%, p = .002), HR (81.0%, p .001), DBP (8.0%, p .001), and SBP (3.0%, p .001). In the multivariable analysis, time of residency had a negative correlation with HR during the emergency (adjusted R-square = .168; F = 8.69; p = .006), SBP response (adjusted R-square = .210; F = 6.19; p = .005) and DBP response (adjusted R-square = .293; F = 9.09; p = .001). Trait anxiety (STAI-t) was positively correlated with STAI-s (adjusted R-square = .326; F = 19.9; p .001), and number of procedures performed during emergency care had a positive association with HR response (adjusted R-square = .241; F = 5.02; p = .005). In the present study, emergency care provoked substantial acute stress in residents. Resident experience, trait anxiety, and number of emergency procedures were independently associated with acute stress response.

Objective Our main objective was to assess patient and family members' perception of bad news communication in the emergency department (ED) and compare these with physicians' perceptions. Methods This is a cross-sectional study carried out at the ED of a tertiary teaching hospital. To compare physicians' and receivers' (patient and/or family member) perceptions, we created a survey based on the six attributes derived from the SPIKES protocol. The surveys were applied immediately after communication of bad news occurred in the ED. We analyzed agreement among participants using κ-statistics and the χ-test to compare proportions. Results A total of 73 bad news communication encounters were analyzed. The survey respondents were 73 physicians, 69 family members, and four patients. In general, there is a low level of agreement between physicians' and receivers' perceptions of how breaking bad news transpired. The satisfaction level of receivers, in terms of breaking bad news by doctors, presented a mean of 3.7±0.6 points. In contrast, the physicians' perception of the communication was worse (2.9±0.6 points), with P value less than 0.001. Conclusion Doctors and receivers disagree in relation to what transpired throughout bad news communications. Discrepancies were more evident in issues involving emotion, invitation, and privacy. An important agreement between perceptions was found in technical and knowledge-related aspects of the communication.

BACKGROUND: Acquired immunodeficiency syndrome (AIDS) is a pandemic disease commonly associated with respiratory infections, hypoxemia, and death. Noninvasive PEEP has been shown to improve hypoxemia. In this study, we evaluated the physiologic effects of different levels of noninvasive PEEP in hypoxemic AIDS patients. METHODS: Thirty AIDS patients with acute hypoxemic respiratory failure received a randomized sequence of noninvasive PEEP (5, 10, or 15 cm H2O) for 20 min. PEEP was provided through a facial mask with pressure-support ventilation (PSV) of 5 cm H2O and an FIO2 of 1. Patients were allowed to breathe spontaneously for a 20-min washout period in between each PEEP trial. Arterial blood gases and clinical variables were recorded after each PEEP treatment. RESULTS: The results indicate that oxygenation improves linearly with increasing levels of PEEP. However, oxygenation levels were similar regardless of the first PEEP level administered (5, 10, or 15 cm H2O), and only the subgroup that received an initial treatment of the lowest level of PEEP (ie, 5 cm H2O) showed further improvements in oxygenation when higher PEEP levels were subsequently applied. The PaCO2 also increased in response to PEEP elevation, especially with the highest level of PEEP (ie, 15 cm H2O). PSV of 5 cm H2O use was associated with significant and consistent improvements in the subjective sensations of dyspnea and respiratory rate reported by patients treated with any level of PEEP (from 0 to 15 cm H2O). CONCLUSIONS: AIDS patients with hypoxemic respiratory failure improve oxygenation in response to a progressive sequential elevation of PEEP (up to 15 cm H2O). However, corresponding elevations in PaCO2 limit the recommended level of PEEP to 10 cm H2O. At a level of 5 cm H2O, PSV promotes an improvement in the subjective sensation of dyspnea regardless of the PEEP level employed.

Summary Objectives: Assess the effect of re-expansive respiratory patterns associated to respiratory biofeedback (RBF) on pulmonary function, respiratory muscle strength and habits in individuals with functional mouth breathing (FMB). Methods: Sixty children with FMB were divided into experimental and control groups. The experimental group was submitted to 15 sessions of re-expansive respiratory patterns associated to RBF (biofeedback pletsmovent; MICROHARD 1 V1.0), which provided biofeedback of the thoracic and abdominal movements. The control group was submitted to 15 sessions using biofeedback alone. Spirometry, maximum static respiratory pressure measurements and questions regarding habits (answered by parents/guardians) were carried out before and after therapy. The Student’s t-test for paireddata andnon-parametric tests were employedfor statistical analysis at a5% level of significance. Results: Significant changes were found in forced vital capacity, Tiffeneau index scores, maximum expiratory pressure, maximum inspiratory pressure and habits assessed in FMB with the use of RBF associated to the re-expansive patterns. No significant differences were found comparing the experimental and control groups. Conclusions: The results allow the conclusion that RBF associated to re-expansive patterns improves forced vital capacity, Tiffeneau index scores, respiratory muscle strength and habits in FMB and can therefore be used as a form of therapy for such individuals.

Background Obesity is associated with increased sympathetic activity and higher mortality. Treatment of this condition is often frustrating. Roux-en-Y gastric bypass is the most effective technique nowadays for treatment of obesity. The aim of the present study is to assess the effects of this surgery on the cardiac autonomic activity, including the influence of gender and age, through heart rate variability (HRV) analysis. Methods The study group consisted of 71 obese patients undergoing gastric bypass. Time domain measures of HRV, obtained from 24-h Holter recordings, were evaluated before and 6 months after surgery, and the results were compared. Percentage of interval differences of successive normal sinus beats greater than 50 ms (pNN50) and square root of the mean squared differences of successive normal sinus beat intervals (rMSSD) was used to estimate the short-term components of HRV, related to the parasympathetic activity. Standard deviation of intervals between all normal sinus beats (SDNN) was related to overall HRV. Results SDNN, pNN50, and rMSSD showed significant increase 6 months after surgery (p

Background Patients with cirrhosis have high risk of bacterial infections and cirrhosis decompensation, resulting in admission to emergency department (ED). However, there are no criteria developed in the ED to identify patients with cirrhosis with bacterial infection and with high mortality risk. Study objective The objective of the study is to identify variables from ED arrival associated with bacterial infections and inhospital mortality. Methods This is a retrospective single-center study using a tertiary hospital's database to identify consecutive ED patients with decompensated cirrhosis. Clinical variables and laboratory results were obtained by chart review. Logistic regression models were built to determine variables independently associated with bacterial infection and mortality. Scores using these variables were designed. Results One hundred forty-nine patients were enrolled, most of them males (77.9%) with alcoholic cirrhosis (53%) and advanced liver disease (Child-Pugh C, 47.2%). Bacterial infections were diagnosed in 72 patients (48.3%), and 36 (24.2%) died during hospital stay. Variables independently associated with bacterial infection were lymphocytes less than or equal to 900/mm 3 (odds ratio [OR], 3.85 [95% confidence interval {CI}, 1.47-10]; P = .006) and C-reactive protein greater than 59.4 mg/L (OR, 5.05 [95% CI, 1.93-13.2]; P = .001). Variables independently associated with mortality were creatinine greater than 1.5 mg/dL (OR, 4.35 [95% CI, 1.87-10.1]; P = .001) and international normalized ratio greater than 1.65 (OR, 3.71 [95% CI, 1.6-8.61]; P = .002). Scores designed to predict bacterial infection and mortality (Mortality in Cirrhosis Emergency Department Score) had an area under the receiver operating characteristic curve of 0.82 and 0.801, respectively. The Mortality in Cirrhosis Emergency Department Score performed better than Model for End-Stage Liver Disease score. Conclusions In this cohort of ED patients with decompensated cirrhosis, lymphopenia and elevated C-reactive protein were related to bacterial infections, and elevated creatinine and international normalized ratio were related to mortality. Scores built with these variables should be prospectively validated.

dence of venous lesions after permanent pacemaker insertion is around 45%. However, this incidence has been based on retrospective studies in a small series; moreover, factors predicting the development of these venous injuries have not been clearly defined. The aim of this study was to identify the risk factors for higher incidence of upper extremity deep vein thrombosis after transvenous permanent pacemaker insertion. The study included 229 patients and the criteria were age above 12 years and first permanent transvenous pacemaker implant. Exclusion criteria were pulmonary embolism, lower or upper extremity deep venous thrombosis, previous use of central venous catheters, coagulation disturbances, and malignancy. Age, race, sex, underlying cardiac disease, functional class to heart failure, LVEF, venous access, number, material and caliber of the leads, and previous use of a transvenous temporary pacemaker were considered. Six months after the pacemaker was implanted, 202 patients were submitted to digital subtraction venography ipsilateral to pacemaker implant. The venographies were normal in 73 (36%) patients and abnormal in 129 (64%) patients. Patients with previous use of transvenous temporary leads (P 5 0,0001, OR 5 4,260, confidence limits 5 2,133‐ 8,465) and LVEF # 40% (P 5 0,0378, OR 5 3,437, confidence limits 5 1,064‐ 12,326), had higher incidence of venous lesions. Previous use of a temporary pacemaker and LVEF # 0.40 were considered independent risk factors to a higher incidence of venous stenosis or thrombosis 6 months after permanent pacemaker insertion. (PACE 2002; 25:1301‐ 1306) pacemaker, vein thrombosis, prothesis implant, superior vena cava, risk factors, prospective studies

Despite the severity of pneumonia in patients with pandemic influenza A infection (H1N1), no validated risk scores associated with H1N1 pneumonia were tested. In this prospective observational study, we analyzed data of consecutive patients in our emergency room, hospitalized because of pneumonia between July and August 2009 in a public hospital in Brazil. The following pneumonia scoring systems were applied: the SMART-COP rule; the Pneumonia Severity Index; and the CURB-65 rule. Of 105 patients with pneumonia, 53 had H1N1 infection. Among them, only 9.5% that had a low risk according to SMART-COP were admitted to ICU, compared with 36.8% of those with the Pneumonia Severity Index score of 1-2 and 49% of those with CURB-65 score of 0-1. The SMART-COP had an accuracy of 83% to predict ICU admission. The SMART-COP rule presented the best performance to indicate ICU admission in patients with H1N1 pneumonia.

Although Aspergillus is widespread, clinically significant disease is rare in immunocompetent patients. We present a case of an otherwise healthy individual who developed cerebral vasculitis and stroke symptoms from Aspergillus, to raise awareness of this entity.

Introduction Triage protocols are only initiated when it is apparent that resource deficits will occur across a broad geographical area despite efforts to expand or acquire additional capacity. Prior to the pandemic the UK Department of Health (DOH) recommended the use of a staged triage plan incorporating Sepsis-related Organ Failure Assessment (SOFA) developed by the Ontario Ministry of Health to assist in the triage of critical care admissions and discharges during an influenza outbreak in the UK. There are data to suggest that had it been used in the recent H1N1 pandemic it may have led to inappropriate limitation of therapy if surge capacity had been overwhelmed. Methods We retrospectively reviewed the performance of the Simple Triage Scoring System (STSS) as an indicator of the utilization of hospital resources in adult patients with confirmed H1N1 admitted to a university teaching hospital. Our aim was to compare it against the staged initial SOFA score process with regards to mortality, need for intensive care admission and requirement for mechanical ventilation and assess its validity. Results Over an 8 month period, 62 patients with confirmed H1N1 were admitted. Forty (65%) had documented comorbidities and 27 (44%) had pneumonic changes on their admission CXR. Nineteen (31%) were admitted to the intensive care unit where 5 (26%) required mechanical ventilation (MV). There were 3 deaths. The STSS group categorization demonstrated a better discriminating accuracy in predicting critical care resource usage with a receiver operating characteristic area under the curve (95% confidence interval) for ICU admission of 0.88 (0.78-0.98) and need for MV of 0.91 (0.83-0.99). This compared to the staged SOFA score of 0.77 (0.65-0.89) and 0.87 (0.72-1.00) respectively. Low mortality rates limited analysis on survival predictions. Conclusions The STSS accurately risk stratified patients in this cohort according to their risk of death and predicted the likelihood of admission to critical care and the requirement for MV. Its single point in time, accuracy and easily collected component variables commend it as an alternative reproducible system to facilitate the triage and treatment of patients in any future influenza pandemic.

To the Editor: First, we would like to thank Dr. Russo for his comments. In his letter, he states that our work confirms the results of previous reports in smaller groups of patients and comments about our selection criteria of obesity patients. Although we really did not include in the exclusion criteria the presence of respiratory disturbances, there was in our group just one patient with history of chronic pneumopathy. The others have no diagnosis of respiratory diseases. We described in our paper that the number of patients with antihypertensive drugs decreased from 25 to six patients 6 months after surgery. In his letter, Russo comments the absence of information about angiotensinconverting enzyme inhibitors (ACE inhibitors) and angiotensin II receptors blockers (ARBs), others drugs (steroid hormones, antidepressants, appetite suppressants), and smoking. In fact, we found in our group ten patients using ACE inhibitors before surgery and just one patient 6 months after surgery. Three patients were using ARBs before and none after. There were no patients using sex steroid hormones or appetite suppressants. No patient was using antidepressants before surgery and just one patient was using after (fluoxetine). Six patients were smokers before

The purpose of this study was to develop a more efficient and stable model of ventricular fibrillation (VF) in the isolated rabbit heart, because there is not a satisfactory model with this animal. We also observed the effects of increasing extracellular calcium in the stability and reversibility of the arrhythmia. After suspending the hearts in a classical Langendorff preparation, VF was induced by burst stimulation (current = 2.0 mA, pulse duration = 3 milliseconds, frequency = 50 Hz, voltage = 10 V, duration of stimulation = 5 minutes). The hearts were then divided into 2 groups, A and B. The hearts in group B were perfused with a modified Krebs-Henseleit solution, which contained twice as much calcium as the solution used in the other group. The rate of success with this model was 100% for both groups. The hearts fibrillated up to 30 minutes in group A and more than 40 minutes in group B, longer then all studies ever published in rabbit hearts. Ventricular fibrillation reverted to sinus rhythm in 100% of the hearts of group A when treated with an antifibrillatory drug, whereas no reversion at all was observed in the hearts of group B. We conclude that high extracellular calcium makes the reversion to sinus rhythm more difficult in this model. Our high rate of success and the exceptionally stable and long-lasting VF turn our model very effective for the study of antiarrhythmic interventions in the isolated rabbit heart.

INTRODUÇÃO: A síndrome da imunodeficiência adquirida (AIDS) é atualmente uma pandemia, e as doenças pulmonares são a principal causa de morbidade e mortalidade dos pacientes com AIDS. Nesse sentido, as infecções respiratórias são frequente causa de hipoxemia e morte. Os pacientes com AIDS e insuficiência respiratória hipoxêmica frequentemente necessitam de ventilação mecânica invasiva, a qual é independentemente associada com mortalidade. A ventilação não invasiva com pressão positiva refere-se à oferta de assistência ventilatória mecânica sem a necessidade de invasão artificial das vias aéreas, sendo reconhecida por melhorar a oxigenação e a dispneia dos pacientes com insuficiência respiratória hipoxêmica, principalmente se aplicada de forma sequencial e progressiva, e esta pode reduzir a necessidade de ventilação mecânica invasiva nestes pacientes. Tendo em vista as incertezas quanto à resposta da oxigenação a PEEP nos pacientes com AIDS com insuficiência respiratória aguda hipoxêmica e usando o racional da pressurização progressiva das vias aéreas e seu potencial benefício na oxigenação sanguínea, nós fizemos a hipótese de que o incremento sequencial dos níveis de PEEP até 15 cmH2O pode melhorar a oxigenação sanguínea sem afetar o conforto e a hemodinâmica do paciente. O objetivo principal deste estudo foi investigar os efeitos de diferentes sequências de níveis de PEEP aplicado de forma não invasiva sobre as trocas gasosas, a sensação de dispneia e os padrões hemodinâmicos em pacientes com AIDS e insuficiência respiratória aguda hipoxêmica. O objetivo secundário foi avaliar o tempo livre de ventilação mecânica invasiva em 28 dias e a mortalidade hospitalar em 60 dias. MÉTODOS: Foram estudados 30 pacientes adultos com HIV/AIDS e insuficiência respiratória aguda hipoxêmica. Todos os pacientes receberam uma sequência randomizada de PEEP não invasivo (os valores usados foram 5, 10 ou 15 cmH2O) por vinte minutos. A PEEP foi fornecida através de máscara facial com pressão suporte (PSV) de 5 cmH2O e uma FiO2 = 1. Um período de washout de 20 minutos com respiração espontânea foi permitido entre cada PEEP. Variáveis clínicas e uma gasometria arterial foram registradas após cada etapa de PEEP. RESULTADOS: Analisando os 30 pacientes, a oxigenação melhorou linearmente com a elevação da PEEP, contudo, estudando os pacientes conforme a PEEP inicial randomizada, a oxigenação foi similar independentemente da primeira PEEP randomizada (5, 10 ou 15 cmH2O), e somente o subgrupo com PEEP inicial = 5 cmH2O melhorou mais a oxigenação quando PEEPs maiores foram usadas. A PaCO2 também aumentou junto com a elevação da PEEP, especialmente com uma PEEP = 15 cmH2O. O uso de PSV = 5 cmH2O foi associado com significante e consistente melhora da sensação subjetiva de dispnéia e da frequência respiratória com PEEP de 0 a 15 cmH2O. CONCLUSÕES: Os pacientes com SIDA e insuficiência respiratória hipoxêmica melhoram a oxigenação com a elevação progressiva e sequencial da PEEP até 15 cmH2O, contudo a elevação da PaCO2 limita a PEEP até 10 cmH2O. Uma PSV = 5 cmH2O promove uma melhora da sensação subjetiva da dispnéia independentemente do uso de PEEP INTRODUTION: The acquired immunodeficiency syndrome (AIDS) is a pandemic, and lung diseases are the leading cause of morbidity and mortality and are often associated with respiratory infections, hypoxemia and death. The noninvasive ventilation with positive pressure refers to the provision of mechanical ventilatory assistance without the need for artificial airway invasion, being recognized for improving oxygenation and dyspnea in patients with hipoxemic respiratory failure. Patients with AIDS and hypoxemic respiratory failure often require invasive mechanical ventilation, which is independently associated with mortality. Given the uncertainties about response in oxygenation with PEEP in patients with AIDS with acute hypoxemic respiratory failure and using the rational for progressive pressurization of the airway and its potential benefits on blood oxygenation, we made the hypothesis that increased levels of sequential PEEP up to 15 cmH2O may improve blood oxygenation without affecting the comfort and hemodynamics of the patient. The main objective of this study was to investigate the effects of different sequences of PEEP levels on gas exchange, the sensation of dyspnea and hemodynamics in patients with AIDS and acute hypoxemic respiratory failure. The secondary objective was to assess the time free of invasive mechanical ventilation in 28 days and hospital mortality within 60 days. METHODS: We studied 30 adults patients with HIV/AIDS and acute hypoxemic respiratory failure. All patients received a randomized sequence of noninvasive PEEP (the values used were 5,10 or 15 cmH2O) for twenty minutes. PEEP was delivered via face mask with pressure support (PSV) of 5 cmH2O and FiO2 = 1. A washout period of 20 minutes with spontaneous breathing was allowed between each PEEP trial. Clinical variables and arterial blood gases were recorded after each PEEP step. RESULTS: Analyzing the 30 patients, oxygenation improved linearly with increasing PEEP, however studying the patients randomized according to the initial PEEP, oxygenation was similar regardless of the first randomized PEEP (5,10 or 15 cmH2O), and only the subgroup with initial PEEP = 5 cmH2O further improve the oxygenation when high PEEP were used. The PaCO2 also rose beside the PEEP elevation, especially with a PEEP = 15 cmH2O. The use of PSV = 5 cmH2O was associated with significant and consistent improvement of subjective sensation of dyspnea and respiratory rate with a PEEP from 0 to 15 cmH2O. CONCLUSION: AIDS-patients with hypoxemic respiratory failure improve oxygenation with a progressive sequential elevation of PEEP up to 15 cmH2O, however the elevation of PaCO2 limit the PEEP up to 10 cmH2O. A PSV = 5 cmH2O promotes an improvement of subjective sensation of dyspnea independently from the use of PEEP

INTRODUÇÃO: Sepse e choque séptico são doenças comuns em pacientes gravemente enfermos, evoluindo muitas vezes com síndrome de disfunção de múltiplos órgãos (SDMO) e morte. Este trabalho investiga a eficácia da administração precoce de dexametasona em evitar a progressão do choque séptico para SDMO e morte e o comportamento da proteína amilóide A sérica (SAA) e da proteína C-reativa (PCR) como marcadores da evolução e gravidade dos pacientes em choque séptico no período pós-operatório. MÉTODOS: Estudo prospectivo, aleatório, duplamente encoberto, realizado na Unidade de Terapia Intensiva pós-operatória do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, com 29 pacientes que no período pós-operatório evoluíram com choque séptico. Os participantes foram divididos de forma aleatória em dois grupos, de acordo com a solução administrada: dexametasona 0,2 mg/kg (grupo D) ou placebo (grupo P), repetidas a cada 36 horas. Os pacientes foram acompanhados durante sete dias de internação na UTI através do escore SOFA (Sequential Organ Failure Assessment) e dosagens séricas diárias de PCR, SAA e lactato. RESULTADOS: Os pacientes do grupo D, quando comparados aos pacientes do grupo P, permaneceram mais dias sem necessidade do uso do vasopressor (respectivamente 2,9±2,7 e 0,7±0,6, p=0,01) e mais tempo livre de ventilação mecânica (respectivamente 2,6±2,5 e 0,6±0,5, p=0,03). A mortalidade no grupo P foi de 67% (10 em 15) e no grupo D foi de 21% (3 em 14) (Risco Relativo=0,31, IC95% 0,11-0,88). Os valores de PCR e SAA apresentaram forte correlação durante o período de observação (R=0,91/p=0,002). PCR e SAA não tiveram correlação com o escore SOFA (respectivamente R=0,71/p=0,05 e R=0,52/p=0,18), nem com o lactato (p=0,88 e p=0,67). CONCLUSÕES: O tratamento precoce com dexametasona nos pacientes com choque séptico reduziu a mortalidade em 7 dias de acompanhamento. Os níveis séricos de PCR e SAA apresentaram-se elevados nos pacientes em choque séptico e tiveram forte correlação, porém não foram preditores de disfunção orgânica nem de mortalidade. INTRODUCTION: Sepsis and septic shock are a very common condition in critically ill patients, leading to multiple organ dysfunction syndrome (MODS) and death. This study aimed at investigating the efficacy of early administration of dexamethasone in patients with septic shock in order to block the evolution to MODS and death. It also evaluated serum amyloid A protein (SAA) and C-reactive protein (CRP) as evolution and organ dysfunction markers in postoperative septic shock patients. METHODS: Prospective, randomized, double-blind study, developed in a surgical intensive care unit of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo that involved 29 patients with septic shock. All eligible patients were prospectively randomized to receive either a dose of 0.2 mg/kg of dexamethasone (group D) or placebo (group P), repeated every 36 hours intervals. Patients were monitored over a 7- day period by Sequential Organ Failure Assessment score (SOFA) and daily measurements of CRP, SAA and lactate. RESULTS: Patients treated with dexamethasone had more vasopressor therapy-free days (2.9±2.7 versus 0.7±0.6, p=0.01) and more mechanical ventilation-free days (2.6±2.5 e 0.6±0.5, p=0.03). Mortality in group P was 67% (10 in 15) and in group D was 21% (3 in 14) (Relative Risk=0.31, 95%CI 0.11 to 0.88). CRP and SAA were strongly correlated during the 7 day period of observation (R=0.91/p=0.002). CRP and SAA did not correlate with SOFA (respectively R=0.71/p=0.05 and R=0.52/p=0.18) and lactate (p=0.88 and p=0.67). CONCLUSIONS: Early treatment with dexamethasone reduced 7-day mortality in septic shock patients. CRP and SAA levels were significantly elevated in septic shock and were strongly correlated to each other, but did neither correlate with organ dysfunction nor predict mortality.