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Editorial
Sepsis, a problem with the size of Brazil
Rev Bras Ter Intensiva. 2006;18(1):5-6
Abstract
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Editorial
Relative adrenal failure and the use of steroids in sepsis: are we closer to a consensus?
Rev Bras Ter Intensiva. 2006;18(1):7-8
Abstract
EditorialRelative adrenal failure and the use of steroids in sepsis: are we closer to a consensus?
Rev Bras Ter Intensiva. 2006;18(1):7-8
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Artigo Original Destaque
An epidemiological study of sepsis in Intensive Care Units: Sepsis Brazil study
Rev Bras Ter Intensiva. 2006;18(1):9-17
Abstract
Artigo Original DestaqueAn epidemiological study of sepsis in Intensive Care Units: Sepsis Brazil study
Rev Bras Ter Intensiva. 2006;18(1):9-17
DOI 10.1590/S0103-507X2006000100003
Views0See moreBACKGROUND AND OBJECTIVES: Sepsis represents the major cause of death in the ICUs all over the world. Many studies have shown an increasing incidence over time and only a slight reduce in mortality. Many new treatment strategies are arising and we should define the incidence and features of sepsis in Brazil. METHODS: Prospective cohort study in sixty-five hospitals all over Brazil. The patients who were admitted or who developed sepsis during the month of September, 2003 were enrolled. They were followed until the 28th day and/or until their discharge. The diagnoses were made in accordance to the criteria proposed by ACCP/SCCM. It were evaluated demographic features, APACHE II score, SOFA (Sepsis-related Organ Failure Assessment) score, mortality, sources of infections, microbiology, morbidities and length of stay (LOS). RESULTS: Seventy-five ICUs from all regions of Brazil took part in the study.3128 patients were identified and 521 (16.7%) filled the criteria of sepsis, severe sepsis or septic shock. Mean age was 61.7 (IQR 39-79), 293 (55.7%) were males, and the overall 28-day mortality rate was 46.6%. Average APACHE II score was 20 and SOFA score on the first day was 7 (IQR 4-10). SOFA score in the mortality group was higher on day 1 (8, IQR 5-11), and had increased on day 3 (9, IQR 6-12). The mortality rate for sepsis, severe sepsis and septic shock was 16.7%, 34.4% and 65.3%, respectively. The average LOS was 15 days (IQR 5-22). The two main sources of infection were the respiratory tract (69%) and the abdomen one (23.1%). Gram-negative bacilli were more prevalent (40.1%). Gram-positive cocci were identified in 32.8% and fungi infections in 5%. Mechanical ventilation was observed in 82.1% of the patients, Swan-Ganz catheter in 18.8%, vasopressors in 66.2% and hemotransfusion in 44.7%. CONCLUSIONS: It was observed a high mortality of sepsis in the ICUs in Brazil. The high frequency of septic shock demonstrated a group at high risk of death. In order to have a better use of the resources and reduce in mortality during the next 5 years, it is very important to identify our specific features related to this syndrome.
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Artigo Original
Severity of patients admitted to a Brazilian teaching hospital Intensive Care Unit
Rev Bras Ter Intensiva. 2006;18(1):18-21
Abstract
Artigo OriginalSeverity of patients admitted to a Brazilian teaching hospital Intensive Care Unit
Rev Bras Ter Intensiva. 2006;18(1):18-21
DOI 10.1590/S0103-507X2006000100004
Views0See moreBACKGROUND AND OBJECTIVES: The aim of this study was to analyze the morbidity and the mortality of critically ill patients admitted to the intensive care unit in a teaching hospital, using the APACHE II score. METHODS: Descriptive and retrospective study, with analysis of 300 patients admitted to ICU from March 2004 to July 2005. RESULTS: Of the 300 patients admitted to ICU, 51.7% were men, average 54.2 ± 19.57 years and 78% from the wards of the teaching hospital itself. There was more prevalence of patients aged 60 years or older (43%). The main dysfunctions were from the respiratory and cardiocirculatory systems. Length of stay in ICU was 7.51 ± 8.21 days. The mean of APACHE II was 16.48 ± 7.67, with meaningful difference between survivors and deceased patients. The real mortality rate in ICU was 32.7%, without meaningful difference between patients that died before or after 48 hours. The standardized mortality ratio was 1.1. CONCLUSIONS: Despite the severity of the patients admitted to ICU, the standardized mortality ratio suggests a satisfactory quality in the service.
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Metabolic acid-base status in critically ill patients: is standard base excess correlated with serum lactate level?
Rev Bras Ter Intensiva. 2006;18(1):22-26
Abstract
Metabolic acid-base status in critically ill patients: is standard base excess correlated with serum lactate level?
Rev Bras Ter Intensiva. 2006;18(1):22-26
DOI 10.1590/S0103-507X2006000100005
Views0See moreBACKGROUND AND OBJECTIVES: To correlate standard base excess (SBE) with serum lactate level and demonstrate the independent prognostic significance of each one. METHODS: In a retrospective study, we retrieved data from 333 patients of our prospectively collected database of 7-bed medical intensive care unit of a 1800-bed university hospital. RESULTS: The results have shown a poor correlation between SBE and lactate, r = – 0.358, p < 0.001, and an independent prognostic significance of each one when analyzed concomitantly, odds ratio (95% Confidence interval) = 0.996 (0.992 - 0.999) to standard base excess and 1.000 (1.000 - 1.002) to lactate at entrance; and odds ratio (95% Confidence interval ) = 0.990 (0.985 - 0.994) to standard base excess and 1.003 (1.001 - 1.005) to lactate after 24 hours. The accuracy of standard base excess was close to lactate to determine in-intensive care unit death. CONCLUSIONS: The lactic component of the metabolic acidosis is not the major determinant of standard base excess. Serum lactate and SBE are independent outcome predictors in critically ill patients.
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Artigo Original
Occurrence of multi-resistant bacteria in the Intensive Care unit of a Brazilian hospital of emergencies
Rev Bras Ter Intensiva. 2006;18(1):27-33
Abstract
Artigo OriginalOccurrence of multi-resistant bacteria in the Intensive Care unit of a Brazilian hospital of emergencies
Rev Bras Ter Intensiva. 2006;18(1):27-33
DOI 10.1590/S0103-507X2006000100006
Views0See moreBACKGROUND AND OBJECTIVES: Nosocomial infection represents a challenge in clinical practice involving hospitalized patients, as they considerably extend the hospitalization period and morbidity and mortality rates and, at the same time, increase hospital costs. Given their clinical conditions, which require invasive procedures and antimicrobial treatment, hospitalized patients, especially at the Intensive Care Unit, are particularly susceptible to hospital infection. This study aimed to evaluate the occurrence of multiresistant bacteria in patients hospitalized at the Intensive Care Unit of a Brazilian emergency hospital. METHODS: Our retrospective study was approved by the Ethics Committee and considered the period between October 2003 and September 2004. A database was developed through variable coding and double entry, and Statistical Package for Social Sciences (SPSS) software, version 10.0, was used for statistical analysis. RESULTS: Multiresistant bacteria were identified in 68 patients, 47 (69.1%) of whom were men, with 55 years as the mean age. All patients were submitted to endotracheal intubation and central venipuncture. The most frequent bacteria were coagulase-negative Staphylococcus sp. (36.4%), followed by Staphylococcus aureus (19%). Cephalosporin was the most frequently used (21.4%) antimicrobial agent. CONCLUSIONS: Knowledge on infection occurrence provokes reflections on multiresistance, directs educative actions and favors interventions to prevent and control problem situations.
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Artigo Original
Utilization of a high frequency oral oscillatory device with mechanical ventilation
Rev Bras Ter Intensiva. 2006;18(1):34-37
Abstract
Artigo OriginalUtilization of a high frequency oral oscillatory device with mechanical ventilation
Rev Bras Ter Intensiva. 2006;18(1):34-37
DOI 10.1590/S0103-507X2006000100007
Views0See moreBACKGROUD AND OBJECTIVES: The high frequency oral oscillation therapy (HFOO) is carried through a plastic device which promotes the clearance of pulmonary sputum. This possesses a metallic sphere which, oscillates during the expiration, generating oscillatory positive expiratory pressure. The aim of this study was to verify the performance of the national device of HFOO (Shaker, NCS, São Paulo) in relation to frequency of oscillation and expiratory pressure with variation of flow and inclination. METHODS: The device was imprisoned to a circuit that consisted of a pneumotacograph and a mechanical ventilator. This had the varied flow and during this variation the expiratory pressure and the frequency of oscillation of the device were measured in angulations which, varied of +40º to -40º. RESULTS: Significant correlation between flow and expiratory pressure in each level of inclination was found. A bigger frequency of oscillation and pressure was evidenced in the positive angulations with the biggest flows (50 and 60 L/min). CONCLUSIONS: The high frequency oral oscillation device can be used as an assist for the air way clearance therapy during mechanical ventilation.
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Artigo Original
Ventilator-associated pneumonia in surgical Intensive Care Unit
Rev Bras Ter Intensiva. 2006;18(1):38-44
Abstract
Artigo OriginalVentilator-associated pneumonia in surgical Intensive Care Unit
Rev Bras Ter Intensiva. 2006;18(1):38-44
DOI 10.1590/S0103-507X2006000100008
Views0See moreBACKGROUND AND OBJECTIVES: The ventilator-associated pneumonia (VAP) is a severe infection that presents multiple causes which can vary depending on the type of intensive care unit, type of patients, emphasizing the needs for vigilance measures with local data. The aim of this study is to describe the incidence, risk factors and mortality of VAP in patients in a surgical ICU. METHODS: Prospective cohort conducted from January 2004 to January 2005. It was included all the patients in mechanical ventilation, followed daily to collect data about demographics, diagnostic, APACHE II and TISS 28 scores, duration of mechanical ventilation, length of stay, incidence of VAP and mortality. RESULTS: 462 patients were studied; age 57.2 ± 16.6 years, 55% men. The mean APACHE II score was 18.3 and the incidence of VAP was 18.8%. The TISS score at admission OR = 1.050 (IC 95%: 1.003-1.050) and the enteral nutrition OR = 5.609 (IC 3.351-9.388) were factors associated with VAP and the prophylactic use of antibiotics was a factor of protection OR = 0.399 (IC95%: 0.177-0.902). The patients with VAP had longer length of stay in ICU (10.3 ± 10.7 vs 4.9 ± 3.3 days), higher median of duration of mechanical ventilation (4 vs 1 days), higher mean of TISS 28 (24.4 ± 4.6 vs 22.8 ± 4.5), and higher crude mortality (46 vs 28.8%) when compared with the patients without VAP. CONCLUSIONS: VAP was a frequent infection in surgical patients in mechanical ventilation. Enteral nutrition and admission TISS were risk factors and the previous use of antibiotics was protection factor to develop VAP. In our sample the results demonstrate that VAP is associated with higher duration in mechanical ventilation, longer length of stay and higher mortality.
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Quality and humanization of the attendance in Intensive Care Medicine. What the parents think’s?
Rev Bras Ter Intensiva. 2006;18(1):45-51
Abstract
Quality and humanization of the attendance in Intensive Care Medicine. What the parents think’s?
Rev Bras Ter Intensiva. 2006;18(1):45-51
DOI 10.1590/S0103-507X2006000100009
Views0See moreBACKGROUND AND OBJECTIVES: This study aims to describe the view of family members about the quality of care given in a general intensive care unit of a university hospital. METHODS: A questionnaire to evaluate the level of satisfaction with the care was elaborated. The study included family members of patients with a length of stay more than 48h who already had visited the patient one time or more during the period. The exclusion criterion was family of admitted patients with less than 48h of ICU stay, family members who had not visited the patient at all or family members who did not desire to answer the questionnaire for any personal reason. RESULTS: There were 100 relatives interviewed face to face. The most frequent complaint that had generated the greatest concern was the general status of the patient, present in 28% of the interviews. A total of 96% considered the quality of the medical team as excellent or good. However, 15% declared to be unsatisfied with the medical information given and the other 5%, although admitting satisfaction, complained about having to talk with different doctors each day. CONCLUSIONS: Imperfections in the communication appears as the main predictor of unsatisfactory quality of the service in the view of the family members. Although one cannot directly compare the degree of satisfaction between distinct studies due to different methodologies, we considered that in the presented sample the recognition of the most frequent factors of dissatisfaction can point out areas for improvement in the quality of care offered in the ICU.
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Characteristics of septic patients in an intensive care unit of a tertiary private hospital from Recife, northeast of Brazil
Rev Bras Ter Intensiva. 2006;18(1):52-58
Abstract
Characteristics of septic patients in an intensive care unit of a tertiary private hospital from Recife, northeast of Brazil
Rev Bras Ter Intensiva. 2006;18(1):52-58
DOI 10.1590/S0103-507X2006000100010
Views0See moreBACKGROUND AND OBJECTIVES: Establish the clinical, epidemiological and laboratorial characteristics of septic patients in an intensive care unit (ICU) of a tertiary care private hospital from Pernambuco, in the northeast of Brazil. METHODS: Cohort study without intervention that included adult patients admitted in the ICU with sepsis or that developed it during ICU stay, during a 6-month period. The patients were followed during all ICU stay period. Laboratory and clinical data were collected after sepsis diagnosis. ICU admission APACHE II score and the SOFA score during the three first days after inclusion in the study were collected. RESULTS: The study included 199 patients, of whom 67.8% were older than 65 years of age. More than a half (56.3%) survived the septic episode, mean APACHE II was 18.2 ± 6.3 and mean SOFA score was 6.3 ± 3.7. The disease related to the admission in ICU was medical in 85.4%, and the majority of patients had a chronic associated disease. In 79.3% the lungs were the source of sepsis and in 40% of patients the etiologic agent of sepsis was isolated. Amongst laboratory tests, thrombocytopenia (platelets < 100.000/mm³) was observed on 20.6%, fibrinogen was elevated (> 300 mg/dL) on 81.7%, and the activity of antithrombin was low (< 70%) on 32.5% of patients. CONCLUSIONS: The epidemiology of sepsis in this study, in a private hospital of Recife, was no different from what was recently described in Southeast and South of Brazil, United States and Europe.
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The severity assessment of critically ill preeclamptic women: a case-control study
Rev Bras Ter Intensiva. 2006;18(1):59-62
Abstract
The severity assessment of critically ill preeclamptic women: a case-control study
Rev Bras Ter Intensiva. 2006;18(1):59-62
DOI 10.1590/S0103-507X2006000100011
Views0See moreBACKGROUND AND OBJECTIVES: The assessment of illness severity and prognosis of obstetric patients by scoring systems is still a controversial issue. Preeclampsia is a leading cause of severe maternal morbidity and mortality, and a major cause of obstetric admission to intensive care unit. There is paucity of data regarding the predictability of critically ill preeclamptic women and the application of scoring systems to this population. This study aimed to evaluate and compare the application of APACHE II, SAPS II and MPM II scoring systems between a preeclamptic population and a non obstetric female population. METHODS: A case-control study was conducted on 28 preeclamptic women and 56 non obstetric female patients, admitted to a general intensive care unit over a period of 10 years. The predictive accuracy of the prognostic evaluation systems was estimated by the area under the receiver operator characteristic curve. RESULTS: The mortality rate was 21.4% (6:28) for the study group and 35.7% (20:56) for the control group, with an OR = 0.49 (95%CI = 0.17-1.41). The main causes of ICU admission of preeclamptic women were HELLP syndrome, coma and pulmonary edema. In the preeclamptic population, only the MPM II score showed an area under the ROC curve statistically different from 0.500, while in the control group, all scoring systems had their areas under the ROC curves statistically different from 0.500. CONCLUSIONS: The application of APACHE II and SAPS II to evaluate critically ill preeclamptic women may be not appropriate.
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Consenso Brasileiro de Monitorização e Suporte Hemodinâmico
Part II: basic hemodynamic monitoring and the use of pulmonary artery catheter
Rev Bras Ter Intensiva. 2006;18(1):63-77
Abstract
Consenso Brasileiro de Monitorização e Suporte HemodinâmicoPart II: basic hemodynamic monitoring and the use of pulmonary artery catheter
Rev Bras Ter Intensiva. 2006;18(1):63-77
DOI 10.1590/S0103-507X2006000100012
Views1See moreBACKGROUND AND OBJECTIVES: Monitoring of vital functions is one of the most important tools in the management of critically ill patients. Nowadays is possible to detect and analyze a great deal of physiologic data using a lot of invasive and non-invasive methods. The intensivist must be able to select and carry out the most appropriate monitoring technique according to the patient requirements and taking into account the benefit/risk ratio. Despite the fast development of non invasive monitoring techniques, invasive hemodynamic monitoring using Pulmonary Artery Catheter still is one of the basic procedures in Critical Care. The aim was to define recommendations about clinical utility of basic hemodynamic monitoring methods and the Use of Pulmonary Artery Catheter. METHODS: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty-five physicians and nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS: Recommendations were made based on 55 questions about the use of central venous pressure, invasive arterial pressure, pulmonary artery catheter and its indications in different settings. CONCLUSIONS: Evaluation of central venous pressure and invasive arterial pressure, besides variables obtained by the PAC allow the understanding of cardiovascular physiology that is of great value to the care of critically ill patients. However, the correct use of these tools is fundamental to achieve the benefits due to its use.
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Consenso Brasileiro de Monitorização e Suporte Hemodinâmico
Brazilian consensus of monitoring and hemodynamic support – part III: alternative methods for cardiac output monitoring and volemia estimation
Rev Bras Ter Intensiva. 2006;18(1):78-85
Abstract
Consenso Brasileiro de Monitorização e Suporte HemodinâmicoBrazilian consensus of monitoring and hemodynamic support – part III: alternative methods for cardiac output monitoring and volemia estimation
Rev Bras Ter Intensiva. 2006;18(1):78-85
DOI 10.1590/S0103-507X2006000100013
Views0See moreBACKGROUND AND OBJECTIVES: Cardiac output and preload as absolute data do not offer helpful information about the hemodynamic of critically ill patients. However, monitoring the response of these variables to volume challenge or inotropic drugs is a very useful tool in the critical care setting, particularly for patients with signs of tissue hypoperfusion. Although PAC remains the ” gold standard” to measure cardiac output and preload, new and alternative technologies were developed to evaluate these hemodynamic variables. METHODS: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty three physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS: Recommendations regarding the use of arterial pulse pressure variation during mechanical ventilation, continuous arterial pulse contour and lithium dilution cardiac output measurements, esophageal Doppler waveform, thoracic electrical bioimpedance, echocardiography and partial CO2 rebreathing for monitoring cardiac output and preload were created. CONCLUSIONS: The new and less invasive techniques for the measurement of cardiac output, preload or fluid responsiveness are accurate and may be an alternative to PAC in critically ill patients.
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Adrenal insufficiency in sepsis
Rev Bras Ter Intensiva. 2006;18(1):86-94
Abstract
Adrenal insufficiency in sepsis
Rev Bras Ter Intensiva. 2006;18(1):86-94
DOI 10.1590/S0103-507X2006000100014
Views0See moreBACKGROUND AND OBJECTIVES: Corticosteroids were introduced in the treatment of severe infection as early as in the nineteen forties. Several ” negative” randomized controlled trials of high-dose of glucocorticoids given for a short period of time in the early course of severe sepsis or acute respiratory distress syndrome raised serious doubts on the benefit of this treatment. Recently, a link between septic shock and adrenal insufficiency, or systemic inflammation induced glucocorticoids receptor resistance had been established. This finding prompted renewed interest of a replacement therapy with low doses of corticosteroids during longer periods. The goal of this article is to review the key role of corticosteroids in the host response to stress and will update the reader with the new validated indications of corticosteroids treatment in the ICU. CONTENTS: Extensive review of the adrenal physiology and its pathophysiological derangements and clinical implications in critically ill patients. CONCLUSIONS: During sepsis, hemodynamic instability and perpetuation of inflammatory state may result from adrenal insufficiency (AI). Thus, an ACTH test should be performed as soon as possible to identify non overt AI. It should be immediately followed by a replacement therapy with iv bolus of 50 mg of hydrocortisone every 6 hours combined to 50 µg of fludrocortisone once daily. When the results of the ACTH test are available, treatment should be continued for 7 days in the non responders to ACTH and withdraw in the responders. Whether responders to ACTH with high baseline cortisol levels (> 34 µg/dL) have tissue resistance to cortisol and also should receive exogenous hormones remains to be evaluated in clinical trials.
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Review Article
Iatrogenic in Intensive Care Medicine
Rev Bras Ter Intensiva. 2006;18(1):95-98
Abstract
Review ArticleIatrogenic in Intensive Care Medicine
Rev Bras Ter Intensiva. 2006;18(1):95-98
DOI 10.1590/S0103-507X2006000100015
Views1See moreBACKGROUND AND OBJECTIVES: Iatrogenic conditions was due of the medical, correctly intervention or not, justified or not, which harmful consequences to the patient. The cares in Intensive Care Medicine present substantial challenges with relation to the security of the patient. The objective of this article is to make one brief revision of literature on the iatrogenic in its concepts and basic terms and its taxes prevalence in Intensive Care Medicine. CONTENTS: Intensive Care Medicine supplies subsidies that improve the morbidity and mortality, but that also the significant risks of adverse events and serious errors associate. The Iatrogenic can be minimized with the adequate monitorization or can be friction as waited aggravation, idiopathic and if to perpetuate in the anonymity. CONCLUSIONS: It is basic to recognize the necessity of the constant learning and recycling and conscience of the susceptibilities to the error; in this context, the respect for the human being must guide the professional behavior.
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Relato de Caso
Poisoning syndrome due to 2,000 stings of africanized honeybees
Rev Bras Ter Intensiva. 2006;18(1):99-103
Abstract
Relato de CasoPoisoning syndrome due to 2,000 stings of africanized honeybees
Rev Bras Ter Intensiva. 2006;18(1):99-103
DOI 10.1590/S0103-507X2006000100016
Views0See moreBACKGROUND AND OBJECTIVES: Honeybees first used in the honey production came from Europe. They were gentle but their productivity was very low. In 1956 it was brought from Africa some species of honeybees that were more productible but also extremely aggressive. There was an accidental release of those bees, that proliferated by hybridizing with the European honeybees generating a new specimen of bees: the Africanized honeybees. The objective of this article is to suggest a pattern of treatment for this poisoning syndrome, because of the crescent number of these attacks and a few data about it. CASE REPORT: Male, 19 years old, soldier that in the course of his military training was attacked by a swarm of Africanized honeybees. CONCLUSIONS: As the Africanized honeybees are very aggressive, they attack their victims with lots of stings releasing a large quantity of venom. The reactions to the stings can vary from a local inflammatory reaction in non sensibilized people, hipersensibility reaction and anaphylactic shock in sensibilized people and poisoning syndrome when there is a big amount of inoculated venom. The medical attendance to this kind of accident must be as fast as possible. It must be done an adequate clinical support and a quick mechanical remotion of the stingers. The hemodynamic stabilization is a very important point.
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Relato de Caso
Perforation of esofagic mucosa for enteric tube: case report
Rev Bras Ter Intensiva. 2006;18(1):104-108
Abstract
Relato de CasoPerforation of esofagic mucosa for enteric tube: case report
Rev Bras Ter Intensiva. 2006;18(1):104-108
DOI 10.1590/S0103-507X2006000100017
Views0See moreBACKGROUND AND OBJECTIVES: This study is a case report of a patient that was submitted to implant of enteric tube (ET) in the ICU, being evidenced false passage in proximal esophagus during endoscopic procedure, demonstrating tunnel for the submucosa. CASE REPORT: A 77 years old woman, transferred to ICU, where ET was installed (due to difficulty of being carried through both nostrils) being confirmed its position through thoraco-abdominal x-ray. The patient remained around 10 days with the ET, receiving diet, without any alteration. In the 10th day she was evolved with melena and reduction of the values of Hb/Ht, without hemodynamic repercussion. Submitted to the high digestive endoscopic that evidenced ulcer injury to bulbar, of about 2.5 cm, with signals of former bleeding. During the examination, a false passage of the ET in proximal esophagus was visualized: 2 cm below of the crico-faring, tunnel for the submucosa possibly for all above-mentioned segments, following its habitual passage until gastric chamber. CONCLUSIONS: Patients of high risk for esophagus perforation for ET installation can be identified and well-taken care of adjusted they can be used. If to occur perforation, this must be identified how much so early possible, for adequate treatment. The adequate treatment depends of each case and same the clinical therapy can be appropriate in selected cases.
2006, Volume 18, Number 1