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  • Research Letter

    COVID-19 underpinning the inverse equity hypothesis between public and private health care in Brazil

    Crit Care Sci. 2024;36:e20240294en

    Abstract

    Research Letter

    COVID-19 underpinning the inverse equity hypothesis between public and private health care in Brazil

    Crit Care Sci. 2024;36:e20240294en

    DOI 10.62675/2965-2774.20240294-pt

    Views48
    Since 1990, the Brazilian public health care system, known as the Unified Health System (SUS – Sistema Único de Saúde), has provided free health care services to all individuals throughout the country. However, approximately 24.9% of the Brazilian population has the financial means to afford private health care alternatives.() Equity, a fundamental principle of SUS, […]
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    COVID-19 underpinning the inverse equity hypothesis between public and private health care in Brazil
  • Factors associated with blood oxygen partial pressure and carbon dioxide partial pressure regulation during respiratory extracorporeal membrane oxygenation support: data from a swine model

    Rev Bras Ter Intensiva. 2016;28(1):11-18

    Abstract

    Factors associated with blood oxygen partial pressure and carbon dioxide partial pressure regulation during respiratory extracorporeal membrane oxygenation support: data from a swine model

    Rev Bras Ter Intensiva. 2016;28(1):11-18

    DOI 10.5935/0103-507X.20160006

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    ABSTRACT

    Objective:

    The aim of this study was to explore the factors associated with blood oxygen partial pressure and carbon dioxide partial pressure.

    Methods:

    The factors associated with oxygen - and carbon dioxide regulation were investigated in an apneic pig model under veno-venous extracorporeal membrane oxygenation support. A predefined sequence of blood and sweep flows was tested.

    Results:

    Oxygenation was mainly associated with extracorporeal membrane oxygenation blood flow (beta coefficient = 0.036mmHg/mL/min), cardiac output (beta coefficient = -11.970mmHg/L/min) and pulmonary shunting (beta coefficient = -0.232mmHg/%). Furthermore, the initial oxygen partial pressure and carbon dioxide partial pressure measurements were also associated with oxygenation, with beta coefficients of 0.160 and 0.442mmHg/mmHg, respectively. Carbon dioxide partial pressure was associated with cardiac output (beta coefficient = 3.578mmHg/L/min), sweep gas flow (beta coefficient = -2.635mmHg/L/min), temperature (beta coefficient = 4.514mmHg/ºC), initial pH (beta coefficient = -66.065mmHg/0.01 unit) and hemoglobin (beta coefficient = 6.635mmHg/g/dL).

    Conclusion:

    In conclusion, elevations in blood and sweep gas flows in an apneic veno-venous extracorporeal membrane oxygenation model resulted in an increase in oxygen partial pressure and a reduction in carbon dioxide partial pressure 2, respectively. Furthermore, without the possibility of causal inference, oxygen partial pressure was negatively associated with pulmonary shunting and cardiac output, and carbon dioxide partial pressure was positively associated with cardiac output, core temperature and initial hemoglobin.

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    Factors associated with blood oxygen partial pressure and carbon dioxide partial pressure regulation during respiratory extracorporeal membrane oxygenation support: data from a swine model
  • Original Article

    Oxygen delivery, carbon dioxide removal, energy transfer to lungs and pulmonary hypertension behavior during venous-venous extracorporeal membrane oxygenation support: a mathematical modeling approach

    Rev Bras Ter Intensiva. 2019;31(2):113-121

    Abstract

    Original Article

    Oxygen delivery, carbon dioxide removal, energy transfer to lungs and pulmonary hypertension behavior during venous-venous extracorporeal membrane oxygenation support: a mathematical modeling approach

    Rev Bras Ter Intensiva. 2019;31(2):113-121

    DOI 10.5935/0103-507X.20190018

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    ABSTRACT

    Objective:

    To describe (1) the energy transfer from the ventilator to the lungs, (2) the match between venous-venous extracorporeal membrane oxygenation (ECMO) oxygen transfer and patient oxygen consumption (VO2), (3) carbon dioxide removal with ECMO, and (4) the potential effect of systemic venous oxygenation on pulmonary artery pressure.

    Methods:

    Mathematical modeling approach with hypothetical scenarios using computer simulation.

    Results:

    The transition from protective ventilation to ultraprotective ventilation in a patient with severe acute respiratory distress syndrome and a static respiratory compliance of 20mL/cm H2O reduced the energy transfer from the ventilator to the lungs from 35.3 to 2.6 joules/minute. A hypothetical patient, hyperdynamic and slightly anemic with VO2 = 200mL/minute, can reach an arterial oxygen saturation of 80%, while maintaining the match between the oxygen transfer by ECMO and the VO2 of the patient. Carbon dioxide is easily removed, and normal PaCO2 is easily reached. Venous blood oxygenation through the ECMO circuit may drive the PO2 stimulus of pulmonary hypoxic vasoconstriction to normal values.

    Conclusion:

    Ultraprotective ventilation largely reduces the energy transfer from the ventilator to the lungs. Severe hypoxemia on venous-venous-ECMO support may occur despite the matching between the oxygen transfer by ECMO and the VO2 of the patient. The normal range of PaCO2 is easy to reach. Venous-venous-ECMO support potentially relieves hypoxic pulmonary vasoconstriction.

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    Oxygen delivery, carbon dioxide removal, energy transfer to lungs and pulmonary hypertension behavior during venous-venous extracorporeal membrane oxygenation support: a mathematical modeling approach
  • Original Article

    Insights about serum sodium behavior after 24 hours of continuous renal replacement therapy

    Rev Bras Ter Intensiva. 2016;28(2):120-131

    Abstract

    Original Article

    Insights about serum sodium behavior after 24 hours of continuous renal replacement therapy

    Rev Bras Ter Intensiva. 2016;28(2):120-131

    DOI 10.5935/0103-507X.20160026

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    ABSTRACT

    Objective:

    The aim of this study was to investigate the clinical and laboratorial factors associated with serum sodium variation during continuous renal replacement therapy and to assess whether the perfect admixture formula could predict 24-hour sodium variation.

    Methods:

    Thirty-six continuous renal replacement therapy sessions of 33 patients, in which the affluent prescription was unchanged during the first 24 hours, were retrieved from a prospective collected database and then analyzed. A mixed linear model was performed to investigate the factors associated with large serum sodium variations (≥ 8mEq/L), and a Bland-Altman plot was generated to assess the agreement between the predicted and observed variations.

    Results:

    In continuous renal replacement therapy 24-hour sessions, SAPS 3 (p = 0.022) and baseline hypernatremia (p = 0.023) were statistically significant predictors of serum sodium variations ≥ 8mEq/L in univariate analysis, but only hypernatremia demonstrated an independent association (β = 0.429, p < 0.001). The perfect admixture formula for sodium prediction at 24 hours demonstrated poor agreement with the observed values.

    Conclusions:

    Hypernatremia at the time of continuous renal replacement therapy initiation is an important factor associated with clinically significant serum sodium variation. The use of 4% citrate or acid citrate dextrose - formula A 2.2% as anticoagulants was not associated with higher serum sodium variations. A mathematical prediction for the serum sodium concentration after 24 hours was not feasible.

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    Insights about serum sodium behavior after 24 hours of continuous renal replacement therapy
  • Original Articles - Basic Research

    Acute hemodynamic, respiratory and metabolic alterations after blood contact with a volume priming and extracorporeal life support circuit: an experimental study

    Rev Bras Ter Intensiva. 2012;24(2):137-142

    Abstract

    Original Articles - Basic Research

    Acute hemodynamic, respiratory and metabolic alterations after blood contact with a volume priming and extracorporeal life support circuit: an experimental study

    Rev Bras Ter Intensiva. 2012;24(2):137-142

    DOI 10.1590/S0103-507X2012000200007

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    OBJECTIVE: To investigate the hemodynamic, respiratory and metabolic impact of blood contact with a priming volume and extracorporeal membrane oxygenation circuit, before the initiation of oxygenation and ventilation METHODS: Five animals were instrumented and submitted to extracorporeal membrane oxygenation. Data were collected at the baseline and 30 minutes after starting extracorporeal circulation, without membrane ventilatory (sweeper) flow. RESULTS: After starting extracorporeal membrane oxygenation, there was a non-significant elevation in pulmonary vascular resistance from 235 (178,303) to 379 (353,508) dyn.seg.(cm5)-1 (P=0.065), associated with an elevation in the alveolar arterial oxygen gradient from 235 (178,303) to 379 (353,508) mmHg (P=0.063). We also observed a reduction in the left ventricle stroke work from 102 (94,105) to 78 (71,87) (mL.mmHg)/beat (P=0.064), in addition to a reduction in cardiac output from 7.2 (6.8,7.6) to 5.9 (5.8,6.3) L/min (P=0.188). The right ventricle stroke work was counterbalanced between the pulmonary vascular resistance increment and the cardiac output reduction, maintaining a similar value. CONCLUSIONS: We presented an experimental model that is feasible and safe. Blood contact with the priming volume and extracorporeal membrane oxygenation circuit resulted in non-significant systemic or metabolic changes.

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    Acute hemodynamic, respiratory and metabolic alterations after blood contact with a volume priming and extracorporeal life support circuit: an experimental study
  • Original Articles

    Fractional excretion of potassium in the course of acute kidney injury in critically ill patients: potential monitoring tool?

    Rev Bras Ter Intensiva. 2014;26(2):143-147

    Abstract

    Original Articles

    Fractional excretion of potassium in the course of acute kidney injury in critically ill patients: potential monitoring tool?

    Rev Bras Ter Intensiva. 2014;26(2):143-147

    DOI 10.5935/0103-507X.20140021

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    Objective:

    To evaluate the behavior of fractional excretion of potassium in the course of acute kidney injury in critically ill patients.

    Methods:

    As part of a larger study in which we have evaluated blood and urinary parameters in the course of acute kidney injury, 168 patients were included. Blood and urine samples were collected daily until the removal of the urinary catheter or the initiation of renal replacement therapy. We describe the evolution of fractional excretion of potassium based on whether acute kidney injury was diagnosed, its duration (transient or persistent) and its severity (creatinine-based Acute Kidney Injury Network - AKIN stage). The diagnostic performance of fractional excretion of potassium in predicting the duration of acute kidney injury and the need for renal replacement therapy on the day of acute kidney injury diagnosis was also evaluated.

    Results:

    Fractional excretion of potassium was significantly higher in persistent acute kidney injury compared to transient acute kidney injury on the day of acute kidney injury diagnosis (24.8 vs. 13.8%, p<0.001). Both groups had the median fractional excretion of potassium increasing in the two days preceding the acute kidney injury diagnosis. Patients without acute kidney injury had stable low fractional excretion of potassium values. The fractional excretion of potassium was fairly accurate in predicting persistent acute kidney injury (area under the curve: 0.712; 95% confidence interval: 0.614-0.811; p<0.001) on the day of acute kidney injury diagnosis. The area under the curve was 0.663 (95% confidence interval: 0.523-0.803; p=0.03) for renal replacement therapy. The fractional excretion of potassium increased with maximum AKIN stage reached, in both transient and persistent acute kidney injury.

    Conclusion:

    Sequential fractional excretion of potassium assessment appears to be useful in critically ill patients at risk for acute kidney injury.

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    Fractional excretion of potassium in the course of acute
               kidney injury in critically ill patients: potential monitoring tool?
  • Factors associated with variation in intracranial pressure in a model of intra-abdominal hypertension with acute lung injury

    Rev Bras Ter Intensiva. 2011;23(2):164-169

    Abstract

    Factors associated with variation in intracranial pressure in a model of intra-abdominal hypertension with acute lung injury

    Rev Bras Ter Intensiva. 2011;23(2):164-169

    DOI 10.1590/S0103-507X2011000200008

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    OBJECTIVE: To evaluate the effects of hemodynamic, respiratory and metabolic changes on intracranial pressure in a model of acute lung injury and abdominal compartment syndrome. METHODS: Eight Agroceres pigs were submitted to five different clinical scenarios after instrumentation: 1) a baseline condition with low intra-abdominal pressure and healthy lungs; 2) pneumoperitoneum with 20 mmHg intra-abdominal pressure; 3) acute lung injury induced by pulmonary lavage with surfactant deactivation; 4) pneumoperitoneum with 20 mmHg intra-abdominal pressure with lung pulmonary injury and low positive end-expiratory pressure; and 5) 27 cmH2O positive end-expiratory pressure with pneumoperitoneum and acute lung injury. Respiratory and hemodynamic variables were collected. A multivariate analysis was conducted to search for variables associated with increased intracranial pressure in the five scenarios. RESULTS: Only plateau airway pressure showed a positive correlation with intracranial pressure in the multivariate analysis. In the models with acute lung injury, plateau airway pressure, CO2 arterial pressure, end tidal CO2 and central venous pressure were positively correlated with increased intracranial pressure. CONCLUSION: In a model of multiple organ dysfunction with associated clinical conditions causing increased intra-thoracic and abdominal pressure, increased intracranial pressure triggered by elevated intra-abdominal pressure is apparently caused by worsened respiratory system compliance and a reduced brain venous drainage gradient due to increased central venous pressure.

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  • Physicochemical characterization of metabolic acidosis induced by normal saline resuscitation of patients with severe sepsis and septic shock

    Rev Bras Ter Intensiva. 2011;23(2):176-182

    Abstract

    Physicochemical characterization of metabolic acidosis induced by normal saline resuscitation of patients with severe sepsis and septic shock

    Rev Bras Ter Intensiva. 2011;23(2):176-182

    DOI 10.1590/S0103-507X2011000200010

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    OBJECTIVE: The aim of this study was to characterize and quantify metabolic acidosis that was caused by initial volume expansion during the reanimation of patients with severe sepsis and septic shock. METHODS: A blood sample was drawn for physicochemical characterization of the patient's acid-base equilibrium both before and after volume expansion using 30 mL/kg 0.9% saline solution. The diagnosis and quantification of metabolic acidosis were based on the standard base excess (SBE). RESULTS: Eight patients with a mean age of 58 ± 13 years and mean APACHE II scores of 20 ± 4 were expanded using 2,000 ± 370 mL of 0.9% saline solution. Blood pH dropped from 7.404 ± 0.080 to 7.367 ± 0.086 (p=0.018), and PC O2 increased from 30 ± 5 to 32 ± 2 mmHg (p=0.215); SBE dropped from -4.4 ± 5.6 to -6.0 ± 5.7 mEq/L (p=0.039). The drop in SBE was associated with the acidifying power of two factors, namely, a significant increase in the strong ion gap (SIG) from 6.1 ± 3.4 to 7.7 ± 4.0 mEq/L (p = 0.134) and a non-significant drop in the apparent inorganic strong ion differences (SIDai) from 40 ± 5 to 38 ± 4 mEq/L (p = 0.318). Conversely, the serum albumin levels decreased from 3.1 ± 1.0 to 2.6 ± 0.8 mEq/L (p = 0.003) with an alkalinizing effect on SBE. Increased serum chloride levels from 103 ± 10 to 106 ± 7 mEq/L (p < 0.001) led to a drop in SIDai. CONCLUSION: Initial resuscitation using 30 mL/kg of 0.9% saline solution for patients with severe sepsis and septic shock is associated with worsened metabolic acidosis, as measured by SBE. This worsened SBE can be ascribed to a serum increase in the levels of unmeasurable anions and chloride.

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    Physicochemical characterization of metabolic acidosis induced by normal saline resuscitation of patients with severe sepsis and septic shock

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