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Abstract Background Critically ill patients with cirrhosis and ascites are at high risk for intra-abdominal hypertension (IAH) which increases mortality. Clinical guidelines recommend maintaining intra-abdominal pressure (IAP) below 16 mmHg; nonetheless, more than three quarters of critically ill patients with cirrhosis develop IAH during their first week of ICU stay. Standard-of-care intermittent large-volume paracentesis (LVP) relieves abdominal wall tension, reduces IAP, optimizes abdominal perfusion pressure, and is associated with short-term improvement in renal and pulmonary dysfunction. However, there is no evidence of the superiority of different paracentesis strategies in the prevention and treatment of IAH in critically ill patients with cirrhosis. This trial aims to compare the outcomes of continuous passive paracentesis versus LVP in the prevention and treatment of IAH in patients with cirrhosis and ascites. Methods An investigator-initiated, open label, randomized controlled trial, set in a general ICU specialized in liver disease, was initiated in August 2022, with an expected duration of 36 months. Seventy patients with cirrhosis and ascites will be randomly assigned, in a 1:1 ratio, to receive one of two methods of therapeutic paracentesis. A stratified randomization method, with maximum creatinine and IAP values as strata, will homogenize patient baseline characteristics before trial group allocation, within 24 h of admission. In the control group, LVP will be performed intermittently according to clinical practice, with a maximum duration of 8 h, while, in the intervention group, continuous passive paracentesis will drain ascitic fluid for up to 7 days. The primary endpoint is serum creatinine concentration, and secondary endpoints include IAP, measured creatinine clearance, daily urine output, stage 3 acute kidney injury and multiorgan dysfunction assessed at day 7 after enrollment, as well as 28-day mortality rate and renal replacement therapy-free days, and length-of-stay. Prespecified values will be used in case of renal replacement therapy or, beforehand ICU discharge, liver transplant and death. Safety analysis will include paracentesis-related complication rate and harm. Data will be analyzed with an intention-to-treat approach. Discussion This is the first trial to compare the impact of different therapeutic paracentesis strategies on organ dysfunction and outcomes in the prevention and treatment of IAH in critically ill patients with cirrhosis and ascites. Trial registration ClinicalTrials.gov NCT04322201 . Registered on 20 December 2019

Abstract In critical patients, abdominal perfusion pressure (APP) has been shown to correlate with outcome. However, data from cirrhotic patients is scarce. We aimed to characterize APP in critically ill cirrhotic patients, analyze the prevalence and risk factors of abdominal hypoperfusion (AhP) and outcomes. A prospective cohort study in a general ICU specialized in liver disease at a tertiary hospital center recruited consecutive cirrhotic patients between October 2016 and December 2021. The study included 101 patients, with a mean age of 57.2 (± 10.4) years and a female gender proportion of 23.5%. The most frequent etiology of cirrhosis was alcohol (51.0%), and the precipitant event was infection (37.3%). ACLF grade (1–3) distribution was 8.9%, 26.7% and 52.5%, respectively. A total of 1274 measurements presented a mean APP of 63 (± 15) mmHg. Baseline AhP prevalence was 47%, independently associated with paracentesis (aOR 4.81, CI 95% 1.46–15.8, p = 0.01) and ACLF grade (aOR 2.41, CI 95% 1.20–4.85, p = 0.01). Similarly, AhP during the first week (64%) had baseline ACLF grade (aOR 2.09, CI 95% 1.29–3.39, p = 0.003) as a risk factor. Independent risk factors for 28-day mortality were bilirubin (aOR 1.10, CI 95% 1.04–1.16, p

BackgroundLiver cirrhosis and ascites are risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); however, data is scarce. We aimed to determine the prevalence of IAH/ACS in a population of critically ill cirrhotic patients with acute medical illness in intensive care and to assess for risk factors and clinical outcomes.MethodsThis was a multicentric retrospective cohort study including two general ICUs and pooled data from a multicentric study between January 2009 and October 2019.ResultsA total of 9,345 patients were screened, and 95 were included in the analysis. Mean age was 56.7±1.3 years, and 79% were male. Liver cirrhosis etiology included alcohol in 45.3% and alcohol plus hepatitis C virus in 9.5%. Precipitating events included infection in 26% and bleeding in 21% of cases. Mean severity score MELD and SAPS II were 26.2±9.9 and 48.5±15.3, respectively, at ICU admission. The prevalence of IAH and ACS was respectively 82.1% and 23.2% with a mean value of maximum IAP of 16.0±5.7 mmHg and IAH grades: absent 17.9%, I 26.3%, II 33.7%, III 17.9%, and IV 4.2%. Independent risk factors for IAH were alcoholic cirrhosis (p = 0.01), West-Haven score (p = 0.01), and PaO2/FiO2 ratio (p = 0.02); as well as infection (p = 0.048) for ACS. Overall, 28-day mortality was 52.6% associated with higher IAP and ACS, and independent risk factors were MELD (p = 0.001), white blood cell count (p = 0.03), PaO2/FiO2 ratio (p = 0.03), and lactate concentration (p = 0.04) at ICU admission.ConclusionsThis study demonstrates a very high prevalence of IAH/ACS in the critically ill cirrhotic patient in intensive care. Increased IAP and ACS were associated with severity of disease and adverse outcomes and independent risk factors for IAH were alcoholic cirrhosis, hepatic encephalopathy and PO2/FiO2 ratio, as well as infection for ACS. Early diagnosis, prevention, and treatment of IAH/ACS might improve outcome in critically ill cirrhotic patients.

Ischemia and reperfusion injury (IRI) is a common complication caused by inflammation and oxidative stress resulting from liver surgery. Current therapeutic strategies do not present the desirable efficacy, and severe side effects can occur. To overcome these drawbacks, new therapeutic alternatives are necessary. Drug delivery nanosystems have been explored due to their capacity to improve the therapeutic index of conventional drugs. Within nanocarriers, liposomes are one of the most successful, with several formulations currently in the market. As improved therapeutic outcomes have been demonstrated by using liposomes as drug carriers, this nanosystem was used to deliver quercetin, a flavonoid with anti-inflammatory and antioxidant properties, in hepatic IRI treatment. In the present work, a stable quercetin liposomal formulation was developed and characterized. Additionally, an in vitro model of ischemia and reperfusion was developed with a hypoxia chamber, where the anti-inflammatory potential of liposomal quercetin was evaluated, revealing the downregulation of pro-inflammatory markers. The anti-inflammatory effect of quercetin liposomes was also assessed in vivo in a rat model of hepatic IRI, in which a decrease in inflammation markers and enhanced recovery were observed. These results demonstrate that quercetin liposomes may provide a significant tool for addressing the current bottlenecks in hepatic IRI treatment.

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by an acute deterioration of a patient with cirrhosis, frequently associated with multi-organ failure and a high short-term mortality rate. We present a retrospective study that aims to characterize the presentation, evolution, and outcome of patients diagnosed with ACLF at our center over the last 3 years, with a comparative analysis between the group of patients that had ACLF precipitated by infectious insults of bacterial origin and the group of those with ACLF triggered by a nonbacterial infectious insult; the incidence of acute kidney injury and its impact on the prognosis of ACLF was also analyzed. Twenty-nine patients were enrolled, the majority of them being male (89.6%), and the mean age was 53 years. Fourteen patients (48.3%) developed ACLF due to a bacterial infectious event, and 9 of them died (64.2%, overall mortality rate 31%); however, no statistical significance was found (p p p p p p Conclusions: ACLF is a heterogeneous syndrome with a variety of precipitant factors and different grades of extrahepatic involvement. Most cases will have some degree of renal dysfunction, with an increased risk of mortality. Hepatic transplant is an efficient form of therapy for this syndrome.

Objectivos: A insuficiência respiratória parcial aguda (IRPA) grave é uma situação comum na prática dos cuidados intensivos, mas os estudos existentes são insuficientes. Com este trabalho pretendeu-se estudar a prevalência e caracterizar clinicamente a população de doentes internados numa UCI que apresentam insuficiência respiratória parcial aguda grave. Material e métodos: Numa unidade de cuidados intensivos médico-cirúrgica avaliaram-se retrospectivamente os doentes internados durante o ano de 2004. Resultados: 37,6% dos doentes apresentaram IRPA grave. A análise estatística demonstrou que estes doentes diferiam dos doentes sem IRPA nos tempos de internamento e ventilação, índices de gravidade e mortalidade. Conclusão: A IRPA é uma situação com elevada prevalência e relevância em cuidados intensivos, mas as características destes doentes estão mal definidas, em parte devido à ausência de critérios claros na sua definição. Para melhor compreender este fenómeno são necessários mais estudos, prospectivos e multicêntricos.Objective: The authors analysed patients with severe partial respiratory failure (SPRF) admitted to a general Intensive Care Unit (ICU). The prevalence and clinical characteristics of these patients were evaluated. This work aims to study the rate of and to clinically characterise the patient population admitted to an Intensive Care Unit with acute severe partial respiratory failure. Material and methods: In 16-bed ICU of a central Hospital in Lisbon, patients admitted in the year 2004 were analysed. Patients with SPRF were recruited form patients with an ICU stay> 24 hours. They were selected according to PaO2 and FiO2 and clinically characterized. Results: During the study period 472 patients were admitted, and 378 presented an ICU stay> 24 hours and were enrolled. From those, 142 (37.6%) met criteria for SPRF. Of these, 45 (31.7%) a pulmonary aetiology of SPRF was identified. Patients with SRPF were older, had longer ICU stay, and presented higher severity indexes and mortality. The prevalence of adult respiratory distress syndrome was possible to evaluate in the deceased patients with SPRF (n=52). In these we could find 12 (23%) patients that met criteria for that entity. By multivariate analysis the mortality of patients with SRPF correlated with older age and the presence of circulatory failure (p

Nos doentes com infecção pelo vírus da imunodeficiência humana (VIH) o citomegalovírus torna-se um agente de doença importante quando existe imunossupressão avançada. O seu papel como agente de doença pulmonar neste contexto tem sido amplamente debatido. Nos doentes com pneumocistose, a presença do citomegalovírus no pulmão não parece conferir pior prognóstico, excepto nos que recebem terapêutica adjuvante com corticóides. Os autores apresentam dois casos de doentes com infecção VIH e imunossupressão avançada, admitidos na unidade de cuidados intensivos por insuficiência respiratória. Em ambos houve isolamento de Pneumocystis jirovecii no lavado broncoalveolar. Apesar da terapêutica instituída ambos vieram a falecer. A biópsia pulmonar post mortem mostrou, nos dois casos, a presença de Pneumocystis e inclusões por citomegalovírus. Perante este achado tecem-se algumas considerações sobre o papel do citomegalovírus como agente de pneumonia na SIDA e sobre o seu significado como co-infectante na pneumocistose, sobretudo nos casos de falência terapêutica.Cytomegalovirus is capable of causing disease in immunocompromised patients. In people infected by the Human Immunodeficiency Virus (HIV) it becomes an important agent when there is advanced immunosupression. Its role as a pulmonary pathogen in these patients has been questioned. In the case of pneumocystosis the presence of Cytomegalovirus doesn’t seem to worsen prognosis, except in cases where corticosteroids are used. Authors present two cases of patients with HIV infection and advanced immunosupression who were admitted in the intensive care unit for respiratory failure. In both Pneumocystis jirovecii was isolated from bronco-alveolar lavage. Despite of therapy both patients died from refractory hypoxemia. Pulmonary biopsies performed post mortem revealed presence of neumocystis and Cytomegalovirus inclusion bodies. Considering this finding the role of Cytomegalovirus as a cause of pneumonia in AIDS is discussed, highlighting its impact on the outcome of patients with pneumocystosis, especially in cases of therapeutic failure.

Resumo: Nos doentes com infecção pelo vírus da imunodeficiência humana (VIH) o citomegalovírus torna-se um agente de doença importante quando existe imunossupressão avançada. O seu papel como agente de doença pulmonar neste contexto tem sido amplamente debatido. Nos doentes com pneumocistose, a presença do citomegalovírus no pulmão não parece conferir pior prognóstico, excepto nos que recebem terapêutica adjuvante com corticóides.Os autores apresentam dois casos de doentes com infecção VIH e imunossupressão avançada, admitidos na unidade de cuidados intensivos por insuficiência respiratória. Em ambos houve isolamento de Pneumocystis jirovecii no lavado broncoalveolar. Apesar da terapêutica instituída ambos vieram a falecer. A biópsia pulmonar post mortem mostrou, nos dois casos, a presença de Pneumocystis e inclusões por citomegalovírus. Perante este achado tecem-se algumas considerações sobre o papel do citomegalovírus como agente de pneumonia na SIDA e sobre o seu significado como co-infectante na pneumocistose, sobretudo nos casos de falência terapêutica.Rev Port Pneumol 2008; XIV (1): 151-157 Abstract: Cytomegalovirus is capable of causing disease in immunocompromised patients. In people infected by the Human Immunodeficiency Virus (HIV) it becomes an important agent when there is advanced immunosupression. Its role as a pulmonary pathogen in these patients has been questioned. In the case of pneumocystosis the presence of Cytomegalovirus doesnât seem to worsen prognosis, except in cases where corticosteroids are used.Authors present two cases of patients with HIV infection and advanced immunosupression who were admitted in the intensive care unit for respiratory failure. In both Pneumocystis jirovecii was isolated from bronco-alveolar lavage. Despite of therapy both patients died from refractory hypoxemia. Pulmonary biopsies performed post mortem revealed presence of Pneumocystis and Cytomegalovirus inclusion bodies. Considering this finding the role of Cytomegalovirus as a cause of pneumonia in AIDS is discussed, highlighting its impact on the outcome of patients with pneumocystosis, especially in cases of therapeutic failure.Rev Port Pneumol 2008; XIV (1): 151-157 Palavras chave: Citomegalovírus, pneumonia, VIH, Key words: Cytomegalovirus, pneumonia, HIV

Resumo: Objectivos: Determinar a possibilidade de avaliação não invasiva da pressão venosa central (PVC) através da análise da veia cava inferior (VCI), obtida por ecocardiografia transtorácica (ETT).Desenho: Estudo prospectivo com 3 anos de duração.Local: Unidade de Cuidados Intensivos Polivalente (UCIP) de 16 camas.Métodos: Estudados doentes admitidos numa UCIP nos quais se avaliou a PVC em simultâneo com exame ETT que, para além da visualização da VCI, consistiu na obtenção da dimensão das cavidades cardíacas e função sistólica do ventrículo esquerdo. Para a correlação foram utilizados testes estatísticos paramétricos e não paramétricos.Resultados: Admitidos 560 doentes com registo simultâneo de PVC e ETT e incluídos 477 doentes em que foi possível visualizar a VCI, com idade média de 62,6±±17,3 anos, média de internamento de 11,9±18,7 dias, um índice APACHE II médio de 23,9±8,9 e SAPS II médio de 55,7±20,4. Por análise de regressão linear verificou-se uma relação entre a PVC e a dimensão máxima da VCI (p=0,013), o índice da VCI (p=0,001) e a presença de ventilação mecânica (p=0,002). A correlação linear entre a PVC e a dimensão máxima da VCI e respectivo índice foi de 0,34 e 0,44. Por teste de qui-quadrado, verificou-se uma relação estatisticamente significativa entre os seguintes intervalos de valores: índice da VCI >25% e PVC7 mmHg e a dimensão máxima da VCI >10 mm; nos doentes admitidos por exacerbação de doença pulmonar crónica verificou-se uma correlação fraca entre a PVC >7 mmHg e o índice da VCI25% and a CVP 7 mmHg; an IVC maximum dimension10 mmHg and CVP>7 mmHg. Patients with right ventricle enlargement presented a lack of agreement between IVC maximum dimension and CVP7 mmHg was also observed.Conclusions: IVC analysis is a possible way to noninvasively estimate CVP in a medical/surgical ICU. However, patients with right ventricular enlargement and admitted with chronic respiratory failure present a lack of agreement between IVC parameters and low values of CVP. IVC dimension is a marker of chronic disease and IVC index correlated better with CVP.Rev Port Pneumol 2006; XII (6): 637-658 Palavras-chave: Pressão venosa central, ecocardiografia, cuidados intensivos, doença pulmonar crónica, Key-words: Echocardiography, intensive care, central venous pressure, inferior vena cava, chronic respiratory failure

Objectivos: Determinar a possibilidade de avaliação não invasiva da pressão venosa central (PVC) através da análise da veia cava inferior (VCI), obtida por ecocardiografia transtorácica (ETT). Desenho: Estudo prospectivo com 3 anos de duração. Local: Unidade de Cuidados Intensivos Polivalente (UCIP) de 16 camas. Métodos: Estudados doentes admitidos numa UCIP nos quais se avaliou a PVC em simultâneo com exame ETT que, para além da visualização da VCI, consistiu na obtenção da dimensão das cavidades cardíacas e função sistólica do ventrículo esquerdo. Para a correlação foram utilizados testes estatísticos paramétricos e não paramétricos. Resultados: Admitidos 560 doentes com registo simultâneo de PVC e ETT e incluídos 477 doentes em que foi possível visualizar a VCI, com idade média de 62,6 ± 17,3 anos, média de internamento de 11,9 ± 18,7 dias, um índice APACHE II médio de 23,9 ± 8,9 e SAPS II médio de 55,7 ± 20,4. Por análise de regressão linear verificou-se uma relação entre a PVC e a dimensão máxima da VCI (p=0,013), o índice da VCI (p=0,001) e a presença de ventilação mecânica (p=0,002). A correlação linear entre a PVC e a dimensão máxima da VCI e respectivo índice foi de 0,34 e 0,44. Por teste de qui-quadrado, verificou-se uma relação estatisticamente significativa entre os seguintes intervalos de valores: índice da VCI 13mmHg; índice da VCI entre 26 e 50% e PVC entre 8 e 12mmHg; índice da VCI> 51% e PVC> 7mmHg; dimensão máxima da VCI> 20mmHg e PVC> 13 mmHg; dimensão máxima da VCI> 10mm e PVC> 7mmHg. Nos doentes com dilatação do ventrículo direito (VD) observou-se uma relação mais fraca entre a PVC 50%. A dimensão máxima da VCI, mas não o seu índice, correlacionou-se com a dilatação do VD e AD. Conclusões: A análise da VCI por ETT revelou-se útil na avaliação qualitativa da PVC em doentes admitidos numa UCIP. Em doentes com dilatação do VD e admitidos por exacerbação de doença pulmonar crónica, os métodos avaliados não foram fidedignos para valores baixos de PVC. A dilatação da VCI traduz melhor a cronicidade da doença, enquanto o índice da VCI reflecte melhor o estado de volemia.Objectives: To determine the possibility of non-invasive estimation of central venous pressure (CVP) through inferior vena cava (IVC) analysis, using transthoracic echocardiography (TTE). Design: A prospective 3-year study. Setting: A 16-bed medical/surgical Intensive Care Unit (ICU). Methods: Patients admitted to the ICU were enrolled. CVP measurement and TTE (determining cardiac chambers dimension and left ventricular shortening fraction) with IVC analysis (maximum dimension and IVC index) were performed simultaneously. Parametric and non-parametric statistical analysis was performed to establish correlations between variables. Results: 560 patients were admitted to the study, including 477 in whom IVC was analysed, aging 62.2 ± 17.3 years, a mean ICU stay 11.9 ± 18.7 days, a APACHE II score 23.9 ± 8.9 and a SAPS II score 55.7 ± 20.4. Through linear regression analysis CVP was influenced by IVC index (p=0.001), IVC maximum dimension (p=0.013) and presence of mechanical ventilation (p=0.002). A statistically significant correlation was found between the following parameters: an IVC index< 25% and a CVP >13mmHg; an IVC index and a CVP 26%-50%; an IVC index >51% and CVP< 7mmHg; an IVC maximum dimension > 20mm and a CVP >13mmHg; an IVC maximum dimension 7mmHg was observed, and in patients with chronic respiratory failure (who presented a high prevalence of right ventricular enlargement) a lack of agreement between IVC index >50% and CVP< 7mmHg was also observed. Conclusions: IVC analysis is a possible way to noninvasively estimate CVP in a medical/surgical ICU. However, patients with right ventricular enlargement and admitted with chronic respiratory failure present a lack of agreement between IVC parameters and low values of CVP. IVC dimension is a marker of chronic disease and IVC index correlated better with CVP.

Objectivo: estudar determinantes cardiovasculares condicionantes do tempo de ventilação, mortalidade e gravidade de doença em doentes admitidos numa unidade de cuidados intensivos para ventilação mecânica por exacerbação de insuficiência respiratória crónica. Desenho e local: Estudo prospectivo, com duração de 30 meses numa unidade de cuidados intensivos médico-cirúrgica com 14 camas. Material e métodos: Estudados 59 doentes com idade média de 74,7 +/- 9,7 anos, tempo médio de ventilação de 10,8 +/- 12,6 dias, APACHE II médio de 23 +/- 8,3. Avaliaram-se parâmetros ecocardiográficos (dimensões das cavidades, débito cardíaco, estudo Doppler do fluxo transvalvular mitral, estudo da veia cava inferior) e electrocardiográficos (presença de ritmo sinusal ou fibrilhação auricular) nas primeiras 24 horas de internamento na Unidade e parâmetros gasimétricos à saída. Resultados: Um tempo de ventilação mais prolongado associou-se à presença de fibrilhação auricular (p=0,027), à presença conjunta de fibrilhação auricular e uma veia cava inferior dilatada (> 20mm p=0,004) e com níveis séricos de bicarbonato> 35mEq/l na gasimetria obtida à saída (p=0,04). Verificaram-se 12 óbitos. A mortalidade associou-se à presença de dilatação do ventrículo direito (p=0,03) e a uma relação entre o ventrículo direito e o esquerdo> 0,6 (p=0,04). Conclusão: Nos doentes submetidos a ventilação mecânica por exacerbação de insuficiência respiratória crónica, a presença de fibrilhação auricular indica a possibilidade de um período de ventilação mais prolongado, em especial se houver concomitantemente uma veia cava inferior com diâmetro> 20mm. Nestes doentes, a presença de dilatação das cavidades direitas pode indicar uma probabilidade mais elevada de mortalidade.Objective: To study the influence of cardiac status on the length of mechanical ventilation, outcome and disease severity in patients admitted to an Intensive Care Unit (ICU) with exacerbation of chronic respiratory failure. Design and setting: A 30-month prospective study in a 14 bed ICU Patients and methods: Fifty nine patients were enrolled, with a mean age 74.7 +/- 9.7 years, mean length of ventilator support 10.8 +/- 12.6 days, and mean APACHE II score 23 +/- 8.3. Within the first 24 hours of admittance, cardiac chamber dimensions, inferior vena cava (IVC), and mitral transvalvular Doppler were evaluated using transthoracic echocardiography; the cardiac rhythm was recorded (presence of sinus rhythm or atrial fibrillation). Blood gases were evaluated at dis charge. Results: Greater length of ventilation was observed in patients presenting atrial fibrillation (p=0.027), particularly when a dilated IVC was also present (>20mm, p=0.004). A high level of serum bicarbonate (>35mEq/l), was also related with longer ventilation (p=0. 04). Twelve patients died. Mortality was related to the presence of a dilated right ventricle (p=0. 03) and a ratio between right and left ventricle> 0. 6 (p=0.04). Conclusion: Patients submitted to mechanical ventilation due to exacerbation of chronic respiratory failure which present atrial fibrillation require a longer ventilation period, particularly if a dilated IVC is also present. Patients with dilated right cardiac chambers are at an increased risk of a fatal outcome.

Resumo: Objectivo: estudar determinantes cardiovasculares condicionantes do tempo de ventilação, mortalidade e gravidade de doença em doentes admitidos numa unidade de cuidados intensivos para ventilação mecânica por exacerbação de insuficiência respiratória crónica.Desenho e local: Estudo prospectivo, com duração de 30 meses numa unidade de cuidados intensivos médico-cirúrgica com 14 camas.Material e métodos: Estudados 59 doentes com idade média de 74,7 +/- 9,7 anos, tempo médio de ventilação de 10,8 +/- 12,6 dias, APACHE II médio de 23 +/- 8,3. Avaliaram-se parâmetros ecocardiográficos (dimensões das cavidades, débito cardíaco, estudo Doppler do fluxo transvalvular mitral, estudo da veia cava inferior) e electrocardiográficos (presença de ritmo sinusal ou fibrilhação auricular) nas primeiras 24 horas de internamento na Unidade e parâmetros gasimétricos à saída.Resultados: Um tempo de ventilação mais prolongado associou-se à presença de fibrilhação auricular (p=0,027), à presença conjunta de fibrilhação auricular e uma veia cava inferior dilatada (> 20 mm p=0,004) e com níveis séricos de bicarbonato> 35 mEq/l na gasimetria obtida à saída (p=0,04). Verificaram-se 12 óbitos. A mortalidade associou-se à presença de dilatação do ventrículo direito (p=0,03) e a uma relação entre o ventrículo direito e o esquerdo> 0,6 (p=0,04). Conclusão: Nos doentes submetidos a ventilação mecânica por exacerbação de insuficiência respiratória crónica, a presença de fibrilhação auricular indica a possibilidade de um período de ventilação mais prolongado, em especial se houver concomitantemente uma veia cava inferior com diâmetro> 20 mm. Nestes doentes, a presença de dilatação das cavidades direitas pode indicar uma probabilidade mais elevada de mortalidade.Rev Port Pneumol 2006; XII (2): 131-146 Abstract: Objective: To study the influence of cardiac status on the length of mechanical ventilation, outcome and disease severity in patients admitted to an Intensive Care Unit (ICU) with exacerbation of chronic respiratory failure.Design and setting: A 30-month prospective study in a 14 bed ICUPatients and methods: Fifty nine patients were enrolled, with a mean age 74.7 +/â9.7 years, mean length of ventilator support 10.8 +/â12.6 days, and mean APACHE II score 23 +/- 8.3. Within the first 24 hours of admittance, cardiac chamber dimensions, inferior vena cava (IVC), and mitral transvalvular Doppler were evaluated using transthoracic echocardiography; the cardiac rhythm was recorded (presence of sinus rhythm or atrial fibrillation). Blood gases were evaluated at discharge.Results: Greater length of ventilation was observed in patients presenting atrial fibrillation (p=0.027), particularly when a dilated IVC was also present (>20 mm, p=0.004). A high level of serum bicarbonate (>35 mEq/l), was also related with longer ventilation (p=0. 04). Twelve patients died. Mortality was related to the presence of a dilated right ventricle (p=0. 03) and a ratio between right and left ventricle> 0. 6 (p=0.04). Conclusion: Patients submitted to mechanical ventilation due to exacerbation of chronic respiratory failure which present atrial fibrillation require a longer ventilation period, particularly if a dilated IVC is also present. Patients with dilated right cardiac chambers are at an increased risk of a fatal outcome.Rev Port Pneumol 2006; XII (2): 131-146 Palavras-chave: Insuficiência respiratória crónica, ventilação mecânica, ecocardiografia, Key-words: Mechanical ventilation, chronic respiratory failure, echocardiography

RESUMO: Objectivo: avaliar e caracterizar a linfopenia em doentes admitidos numa unidade de cuidados intensivos para suporte ventilatório por exacerbação de insuficiência respiratória crónica e eventual relação com a gravidade da doença.Material e métodos: estudo prospectivo com 6 meses de duração e mais 6 meses de seguimento após alta da unidade. Incluídos 24 doentes, 22 homens, com APACHE II médio de 19,7, 3 dos quais com possibilidade de seguimento após a alta. Foram colhidas análises para determinação das subpopulações linfocitárias na admissão e a cada 7 dias de ventilação mecânica. Excluídos doentes com sinais de infecção ou imunossupressão prévia, à excepção dos corticóides.Resultados: a linfopenia foi encontrada em 79,2 % dos doentes com depleção de todas as subpopulações linfocitárias sendo mais expressiva a depleção de linfócitos B CD19+. Esta linfopenia não se relacionou com os níveis séricos de cortisol, e apesar de se relacionar com uma maior gravidade clínica não esteve associada a uma maior mortalidade. O registo evolutivo no internamento mostrou tendencialmente uma recuperação da linfopenia.Conclusões: a linfopenia é frequente em doentes ventilados por exacerbação de doença respiratória crónica. Trata-se de uma linfopenia não selectiva, que recupera ao longo do internamento, mais acentuada ao nível dos linfócitos B CD19+. Estes doentes apresentam indices de gravidade maior mas sem diferenças na mortalidade. O seguimento ambulatório destes doentes mostrou-se difícil e foi inconclusivo.REV PORT PNEUMOL 2004; X (5): 373-381 ABSTRACT: Objectives: Evaluate and characterize lymphopenia in patients admitted to the Intensive Care Unit (ICU) for mechanical ventilation due to aggravated chronic respiratory failure and its probable relation to severity.Material and methods: Prospective study over a period of 6 months with another 6 months follow-up after ICU discharge. The study included 24 patients, 22 males, with mean APACHE II of 19,7, three of whom with capacity for outpatient follow-up. Lymphocyte subpopulations were determined on admission and every 7 days after mechanical ventilation. Patients with evidence of infection or previous immunossupression, with the exception of steroids, were excluded from the study.Results: Lymphopenia was found in 79,2% of patients with depletion of all lymphocyte series, although with greater expression for B lymphocytes CD19+. This depletion showed no relation with serum steroid levels, and although related to greater clinical severity, no correlation was found with mortality. Lymphocyte values recovered progressively during admission.Conclusions: Lymphopenia is frequent among ventilated patients with chronic respiratory exacerbation. Itâs a non-selective depletion, more evident with CD19+ B lymphocytes. These patients present higher severity scores but no difference in mortality. Outpatient follow-up was difficult and inconclusive.REV PORT PNEUMOL 2004; X (5): 373-381 Palvras-chave: Insuficiência respiratória crónica, ventilação mecânica, linfopenia, Key-words: Chronic respiratory insufficiency, mechanical ventilation, lymphopenia

Liver cirrhosis (LC) can lead to a clinical state of liver failure, which can exacerbate through the course of the disease. New therapies aimed to control the diverse etiologies are now more effective, although the disease may result in advanced stages of liver failure, where liver transplantation (LT) remains the most effective treatment. The extended lifespan of these patients and the extended possibilities of liver support devices make their admission to an intensive care unit (ICU) more probable. In this paper the LC is approached from the point of view of the pathophysiological alterations present in LC patients previous to ICU admission, particularly cardiovascular, but also renal, coagulopathic, and encephalopathic. Infections and available liver detoxifications devices also deserve mentioning. We intend to contribute towards ICU physician readiness to the care for this particular type of patients, possibly in dedicated ICUs.

A pilot study aimed to introduce intraoperative monitoring of liver surgery using transoesophageal echocardiography (TEE) is described. A set of TEE measurements was established as a protocol, consisting of left atrial (LA) dimension at the aortic valve plane; mitral velocity flow integral, calculation of stroke volume and cardiac output (CO); mitral annular plane systolic excursion; finally, right atrial area. A total of 165 measurements (on 21 patients) were performed, 31 occurring during hypotension. The conclusions reached were during acute blood loss LA dimension changed earlier than CVP, and, in one patient, a dynamic left ventricular (LV) obstruction was observed; in 3 patients a transient LV systolic dysfunction was documented. The comparison between 39 CO paired measurements obtained by TEE and PiCCO2 revealed a statistically significant correlation (P

a prospective study to determine the value of transthoracic echocardiography (TTE) in assessing hypotensive patients in a medical/surgical Intensive care Unit (ICU).a 16-bed medical/surgical ICU.patients with hypotension were studied (systolic arterial pressure < 90 mmHg or mean arterial pressure < 60 mmHg, non responsive to fluid therapy in a 30-minute period). TTE was aimed to: exclude severe cardiac dysfunction(abnormalities requiring immediate therapeutic decision); to evaluate other non severe cardiac alterations; to determine cardiac index (CI) and analyse inferior vena cava (IVC).Two hundred eight patients were studied, and 198 enrolled (4.5% of impossible examinations), with a mean age 63.4 +/- 16.2 years, 129 male, APACHE II score 30.1 +/- 9.9, SAPS II 68.8 +/- 20.5, SOFA 11.6 +/- 3.8, MODS 10.9 +/- 3.9. Mortality was 51% (n=101) and 168 (82.2%) patients were under mechanical ventilation. Forty four patients (44.4%) presented cardiac abnormalities, 28 of whom (14%) severe cardiac diseases. Of these, 18 (9%) presented unsuspected situations (aortic stenosis, 3; endocarditis, 4, dilated miocardiopathy, 9, cardiac tamponade, 2). Patients with cardiac abnormalities were older and presented higher severity scores and mortality. Most patients (158, 79.7%) presented a normal/high IC, all with low peripheral vascular resistance. Through logistic regression analysis, a statistically significant between IVC index and ICU stay (p=0.05); IC and IVC index correlated with overall mortality (p=0,008 and 0,041 respectively).Patients with hypotension in a medical/surgical ICU presented a high rate of cardiac abnormalities (44.4%, n=88), including 26 patients with severe diseases, requiring immediate therapeutic decisions. IC and IVC analysis may be useful to determine hemodynamic profile and several TTE parameters may have prognostic value.

Pulmonary capillary wedge pressure (Pw) is an important hemodynamic parameter frequently used in Intensive Care. Much effort was taken by investigators to noninvasively obtain this parameter particularly using echocardiography. The authors reviewed the published works in this field. There are a great number of correlations between echocardiographic variables and Pw, including equations for its precise assessment. Changes in echocardiographic parameters due to modifications in volume status and more recently tissue Doppler evaluation are also related fields. Despite the quality and quantity of investigation, no single method was established or accepted for non-invasive assessment of Pw using echocardiography. The major problems are related to the study of different populations regarding its basic clinical condition and to the complexity of equations described. Non-invasive assessment of Pw in clinical setting using echocardiography is still a hard task for this technique. Probably, the use of echocardiography as a non-invasive tool for hemodynamic assessment should use other methodologies, and not rely on Pw determination.

Comparative study to evaluate the impact of a hybrid renal replacement technique (HRRT) vs a continuous renal replacement technique (haemodiafiltration) on hemodynamic tolerance, azotemic control, and mortality in critical care patients with acute renal failure.a 14-bed Intensive Care Unit (ICU).Two groups of patients were retrospectively compared: patients submitted to continuous renal replacement techniques (CRRT) in 2003 (n = 26) and patients who underwent HRRT in 2004 (n = 27). Both groups had similar severity scores and underlying diseases, and were haemodynamically unstable. Urea and creatinine reduction ratio (URR and CRR) in both groups were evaluated.Patients treated with HRRT presented a lower mortality (62% vs 84%), less heparin use, and a higher URR and CRR. Univariate logistic regression showed that an increase in APACHE II was related to an increase in mortality (CI 95%, 1.03-1.26). Odds for mortality for CRRT group were about 3 times higher (CI 95%, 0.86-12.11), but not statistically significant (p = 0.074).HRRT is a valid alternative to CRRT in haemodynamically unstable critically ill patients.

To compare the haemodynamic measurements of cardiac output (CO), central venous pressure (CVP), pulmonary capillary wedge pressure (Pw) and pulmonary artery systolic pressure (PASP), obtained by Swan-Ganz catheter and transthoracic echocardiography.Prospective study in a Medical/Surgical Intensive Care Unit (ICU). A total of 41 post liver transplant patients were enrolled. CO, CVP, Pw and PASP, were simultaneously determined by two independent observers, utilizing a Swan-Ganz catheter and transthoracic echocardiography, using equations described in the literature. A linear correlation and a Bland-Altman analysis were performed.A good correlation between invasive and non- invasive measurements for CO (r=0.97) and CVP (r=0.88) was found, but determinations of Pw (r=0.41) and PASP (r=0.18) did not correlate well. Bias and 95% confidence interval for CO were negligible namely when a CO

RESUMO O programa de transplante de fígado teve início em nosso centro em 1992, e pacientes em pós-operatório de transplante hepático ainda são admitidos à unidade de terapia intensiva. Uma curva de aprendizado do médico intensivista teve então início, com aquisição de habilidades e estabelecimento de uma prática específica. Contudo, muitos dos conceitos se modificaram com o tempo, o que conduziu a uma melhora nos cuidados proporcionados a esses pacientes. A abordagem prática varia entre diferentes centros de transplante de fígado, segundo especificidades locais. Assim, ensejamos apresentar nossa prática para estimular o debate entre diferentes equipes dedicadas, o que tem potencial de permitir a introdução de novas ideias e, possivelmente, melhorar o padrão de cuidados em cada instituição.