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  • Review Article

    Central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio as an indicator of tissue oxygenation: a narrative review

    Rev Bras Ter Intensiva. 2020;32(1):115-122

    Abstract

    Review Article

    Central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio as an indicator of tissue oxygenation: a narrative review

    Rev Bras Ter Intensiva. 2020;32(1):115-122

    DOI 10.5935/0103-507X.20200017

    Views1

    ABSTRACT

    The central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio (Pcv-aCO2/Ca-cvO2) has been proposed as a surrogate for respiratory quotient and an indicator of tissue oxygenation. Some small observational studies have found that a Pcv-aCO2/Ca-cvO2 > 1.4 was associated with hyperlactatemia, oxygen supply dependency, and increased mortality. Moreover, Pcv-aCO2/Ca-cvO2 has been incorporated into algorithms for tissue oxygenation evaluation and resuscitation. However, the evidence for these recommendations is quite limited and of low quality. The goal of this narrative review was to analyze the methodological bases, the pathophysiologic foundations, and the experimental and clinical evidence supporting the use of Pcv-aCO2/Ca-cvO2 as a surrogate for respiratory quotient. Physiologically, the increase in respiratory quotient secondary to critical reductions in oxygen transport is a life-threatening and dramatic event. Nevertheless, this event is easily noticeable and probably does not require further monitoring. Since the beginning of anaerobic metabolism is indicated by the sudden increase in respiratory quotient and the normal range of respiratory quotient is wide, the use of a defined cutoff of 1.4 for Pcv-aCO2/Ca-cvO2 is meaningless. Experimental studies have shown that Pcv-aCO2/Ca-cvO2 is more dependent on factors that modify the dissociation of carbon dioxide from hemoglobin than on respiratory quotient and that respiratory quotient and Pcv-aCO2/Ca-cvO2 may have distinct behaviors. Studies performed in critically ill patients have shown controversial results regarding the ability of Pcv-aCO2/Ca-cvO2 to predict outcome, hyperlactatemia, microvascular abnormalities, and oxygen supply dependency. A randomized controlled trial also showed that Pcv-aCO2/Ca-cvO2 is useless as a goal of resuscitation. Pcv-aCO2/Ca-cvO2 should be carefully interpreted in critically ill patients.

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    Central venous minus arterial carbon dioxide pressure to arterial minus central venous oxygen content ratio as an indicator of tissue oxygenation: a narrative review
  • Editorial

    The relationship of postocclusive reactive hyperemia assessed by the plethysmographic perfusion index to lactate clearance: a new piece in the unsolved puzzle of tissue perfusion and oxygenation in septic shock

    Crit Care Sci. 2023;35(2):115-116

    Abstract

    Editorial

    The relationship of postocclusive reactive hyperemia assessed by the plethysmographic perfusion index to lactate clearance: a new piece in the unsolved puzzle of tissue perfusion and oxygenation in septic shock

    Crit Care Sci. 2023;35(2):115-116

    DOI 10.5935/2965-2774.2023.Edit-2.v35n2-pt

    Views7
    Septic shock is commonly characterized by the lack of coherence between systemic hemodynamics and microcirculation.() The optimization of systemic cardiovascular variables frequently fails to improve the outcome of septic patients. Since the final goal of resuscitation should be the normalization of tissue perfusion and oxygenation, there is a growing interest in the monitoring of microvascular […]
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  • Original Articles

    Augmented renal clearance in critically ill patients: incidence, associated factors and effects on vancomycin treatment

    Rev Bras Ter Intensiva. 2014;26(1):13-20

    Abstract

    Original Articles

    Augmented renal clearance in critically ill patients: incidence, associated factors and effects on vancomycin treatment

    Rev Bras Ter Intensiva. 2014;26(1):13-20

    DOI 10.5935/0103-507X.20140003

    Views20

    Objective:

    An augmented renal clearance has been described in some groups of critically ill patients, and it might induce sub-optimal concentrations of drugs eliminated by glomerular filtration, mainly antibiotics. Studies on its occurrence and determinants are lacking. Our goals were to determine the incidence and associated factors of augmented renal clearance and the effects on vancomycin concentrations and dosing in a series of intensive care unit patients.

    Methods:

    We prospectively studied 363 patients admitted during 1 year to a clinical-surgical intensive care unit. Patients with serum creatinine >1.3mg/dL were excluded. Creatinine clearance was calculated from a 24-hour urine collection. Patients were grouped according to the presence of augmented renal clearance (creatinine clearance >120mL/min/1.73m2), and possible risk factors were analyzed with bivariate and logistic regression analysis. In patients treated with vancomycin, dosage and plasma concentrations were registered.

    Results:

    Augmented renal clearance was present in 103 patients (28%); they were younger (48±15 versus 65±17 years, p<0.0001), had more frequent obstetric (16 versus 7%, p=0.0006) and trauma admissions (10 versus 3%, p=0.016) and fewer comorbidities. The only independent determinants for the development of augmented renal clearance were age (OR 0.95; p<0.0001; 95%CI 0.93-0.96) and absence of diabetes (OR 0.34; p=0.03; 95%CI 0.12-0.92). Twelve of the 46 patients who received vancomycin had augmented renal clearance and despite higher doses, had lower concentrations.

    Conclusions:

    In this cohort of critically ill patients, augmented renal clearance was a common finding. Age and absence of diabetes were the only independent determinants. Therefore, younger and previously healthy patients might require larger vancomycin dosing.

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    Augmented renal clearance in critically ill patients:
               incidence, associated factors and effects on vancomycin treatment
  • Fluids in the postoperative period: effects of lack of adjustment to body weight

    Rev Bras Ter Intensiva. 2011;23(2):170-175

    Abstract

    Fluids in the postoperative period: effects of lack of adjustment to body weight

    Rev Bras Ter Intensiva. 2011;23(2):170-175

    DOI 10.1590/S0103-507X2011000200009

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    OBJECTIVE: To compare the differences in fluid and electrolyte balance in patients with low and high weight in the first postoperative day. METHODS: Over a period of 18 months, we prospectively evaluated 150 patients in the first 24 hours after surgery, in a university-affiliated hospital intensive care unit. Patients with low weight (< 60 kg) and high body weight (> 90 Kg) were compared in terms of fluid intake and output. RESULTS: No significant differences were observed in the volume (4334 ± 1097 vs. 4644 ± 1957 ml/24 h) and composition of the fluids administered (481 ± 187 vs. 586 ± 288 mEq [Na+]administered/24 h). The 24 h urine output was similar (2474 ± 1597 vs.2208 ± 678 ml/24 h) but low weight group showed higher electrolyte elimination (296 ± 195 vs.192 ± 117 mEq [Na+]urine /24 h, p = 0.0246). When the administered fluids were adjusted for body weight, the volume and amount of electrolytes of fluids administered were higher in the low weight group (79 ± 21 vs. 47 ± 22 ml/kg/24 h, p < 0.0001 and 8.8 ± 3.4 vs. 5.8 ± 3.3 mEq [Na+]administered/kg/24 h, p = 0.017, respectively). This group also showed higher urine output and electrolyte elimination (45 ± 28 vs. 22 ± 7 ml/kg/24 h, p = 0.0002 and 5.3 ± 3.5 vs. 1.8 ± 1.2 mEq [Na+]urine/kg/24 h, p < 0.0001, respectively). CONCLUSIONS: The lack of adjustment of the fluid therapy to body weight determined that low weight patients received more fluid than high weight patients according to their body weight. This fluid overload could be compensated by increased urine output and electrolyte elimination.

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  • Original Articles

    Urinary strong ion difference is a major determinant of plasma chloride concentration changes in postoperative patients

    Rev Bras Ter Intensiva. 2013;25(3):197-204

    Abstract

    Original Articles

    Urinary strong ion difference is a major determinant of plasma chloride concentration changes in postoperative patients

    Rev Bras Ter Intensiva. 2013;25(3):197-204

    DOI 10.5935/0103-507X.20130035

    Views2

    OBJECTIVE:

    To show that alterations in the plasma chloride concentration ([Cl-]plasma) during the postoperative period are largely dependent on the urinary strong ion difference ([SID]urine=[Na+]urine+[K+]urine-[Cl-]urine) and not on differences in fluid therapy.

    METHODS:

    Measurements were performed at intensive care unit admission and 24 hours later in a total of 148 postoperative patients. Patients were assigned into one of three groups according to the change in [Cl-]plasma at the 24 hours time point: increased [Cl-]plasma (n=39), decreased [Cl-]plasma (n=56) or unchanged [Cl-]plasma (n=53).

    RESULTS:

    On admission, the increased [Cl-]plasma group had a lower [Cl-]plasma (105±5 versus 109±4 and 106±3mmol/L, p<0.05), a higher plasma anion gap concentration ([AG]plasma) and a higher strong ion gap concentration ([SIG]). After 24 hours, the increased [Cl-]plasma group showed a higher [Cl-]plasma (111±4 versus 104±4 and 107±3mmol/L, p<0.05) and lower [AG]plasma and [SIG]. The volume and [SID] of administered fluids were similar between groups except that the [SID]urine was higher (38±37 versus 18±22 and 23±18mmol/L, p<0.05) in the increased [Cl-]plasma group at the 24 hours time point. A multiple linear regression analysis showed that the [Cl-]plasma on admission and [SID]urine were independent predictors of the variation in [Cl-]plasma 24 hours later.

    CONCLUSIONS:

    Changes in [Cl-]plasma during the first postoperative day were largely related to [SID]urine and [Cl-]plasma on admission and not to the characteristics of the infused fluids. Therefore, decreasing [SID]urine could be a major mechanism for preventing the development of salineinduced hyperchloremia.

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    Urinary strong ion difference is a major determinant of
               plasma chloride concentration changes in postoperative patients
  • Microcirculation in the intensive care unit

    Rev Bras Ter Intensiva. 2011;23(3):249-251

    Abstract

    Microcirculation in the intensive care unit

    Rev Bras Ter Intensiva. 2011;23(3):249-251

    DOI 10.1590/S0103-507X2011000300001

    Views3
    EDITORIAL […]
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  • Original Article

    Statistical analysis plan for early goal-directed therapy using a physiological holistic view – the ANDROMEDA-SHOCK: a randomized controlled trial

    Rev Bras Ter Intensiva. 2018;30(3):253-263

    Abstract

    Original Article

    Statistical analysis plan for early goal-directed therapy using a physiological holistic view – the ANDROMEDA-SHOCK: a randomized controlled trial

    Rev Bras Ter Intensiva. 2018;30(3):253-263

    DOI 10.5935/0103-507X.20180041

    Views11

    ABSTRACT

    Background:

    ANDROMEDA-SHOCK is an international, multicenter, randomized controlled trial comparing peripheral perfusion-targeted resuscitation to lactate-targeted resuscitation in patients with septic shock in order to test the hypothesis that resuscitation targeting peripheral perfusion will be associated with lower morbidity and mortality.

    Objective:

    To report the statistical analysis plan for the ANDROMEDA-SHOCK trial.

    Methods:

    We describe the trial design, primary and secondary objectives, patients, methods of randomization, interventions, outcomes, and sample size. We describe our planned statistical analysis for the primary, secondary and tertiary outcomes. We also describe the subgroup and sensitivity analyses. Finally, we provide details for presenting our results, including mock tables showing baseline characteristics, the evolution of hemodynamic and perfusion variables, and the effects of treatments on outcomes.

    Conclusion:

    According to the best trial practice, we report our statistical analysis plan and data management plan prior to locking the database and initiating the analyses. We anticipate that this procedure will prevent analysis bias and enhance the utility of the reported results.

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    Statistical analysis plan for early goal-directed therapy using a physiological holistic view – the ANDROMEDA-SHOCK: a randomized controlled trial
  • Original Article

    Lack of agreement between different observers and methods in the measurement of capillary refill time in healthy volunteers: an observational study

    Rev Bras Ter Intensiva. 2014;26(3):269-276

    Abstract

    Original Article

    Lack of agreement between different observers and methods in the measurement of capillary refill time in healthy volunteers: an observational study

    Rev Bras Ter Intensiva. 2014;26(3):269-276

    DOI 10.5935/0103-507X.20140038

    Views0

    Objective:

    Peripheral perfusion abnormalities are relevant manifestations of shock. Capillary refill time is commonly used for their evaluation. However, the reproducibility of capillary refill time measurements and their correlation with other variables of peripheral perfusion, have not been comprehensively evaluated. Our goal was to determine, in healthy volunteers, the agreement between different methods of capillary refill time quantification and different observers, as well as their correlation with other markers of peripheral perfusion.

    Methods:

    We studied 63 healthy volunteers. Two observers measured capillary refill time by means of two methods, direct view (CRTchronometer) and video analysis (CRTvideo). We also measured perfusion index (PI) derived from pulse plethysmography and finger pad temperature (Tºperipheral). The agreement between observers and methods was assessed using the Bland and Altman method. Correlations were calculated using Pearson's correlation. A p-value<0.05 was considered significant.

    Results:

    The 95% limits of agreement between the two observers were 1.9 sec for CRTchronometer and 1.7 sec for CRTvideo. The 95% limits of agreement between CRTchronometer and CRTvideo were 1.7 sec for observer 1 and 2.3 sec for observer 2. Measurements of CRTchronometer performed by the two observers were correlated with Tºperipheral. Measurements of CRTvideo performed by the two observers were correlated with Tºperipheral and perfusion index.

    Conclusion:

    In healthy volunteers, measurements of capillary refill time performed by either different observers or different methods showed poor agreement. Nevertheless, capillary refill time still reflected peripheral perfusion as shown by its correlation with objective variables of peripheral perfusion.

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    Lack of agreement between different observers and methods in the
               measurement of capillary refill time in healthy volunteers: an observational
               study

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