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You searched for:"Arnaldo Dubin"
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Rev Bras Ter Intensiva. 2020;32(1):115-122
DOI 10.5935/0103-507X.20200017
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.
Abstract
Rev Bras Ter Intensiva. 2020;32(1):115-122
DOI 10.5935/0103-507X.20200017
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.
Abstract
Crit Care Sci. 2023;35(2):115-116
DOI 10.5935/2965-2774.2023.Edit-2.v35n2-pt
Abstract
Crit Care Sci. 2023;35(2):115-116
DOI 10.5935/2965-2774.2023.Edit-2.v35n2-pt
Abstract
Rev Bras Ter Intensiva. 2014;26(1):13-20
DOI 10.5935/0103-507X.20140003
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.
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.
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.
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.
Abstract
Rev Bras Ter Intensiva. 2014;26(1):13-20
DOI 10.5935/0103-507X.20140003
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.
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.
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.
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.
Abstract
Rev Bras Ter Intensiva. 2011;23(2):170-175
DOI 10.1590/S0103-507X2011000200009
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.
Abstract
Rev Bras Ter Intensiva. 2011;23(2):170-175
DOI 10.1590/S0103-507X2011000200009
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.
Abstract
Rev Bras Ter Intensiva. 2013;25(3):197-204
DOI 10.5935/0103-507X.20130035
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.
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).
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.
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.
Abstract
Rev Bras Ter Intensiva. 2013;25(3):197-204
DOI 10.5935/0103-507X.20130035
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.
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).
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.
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.
Abstract
Rev Bras Ter Intensiva. 2018;30(3):253-263
DOI 10.5935/0103-507X.20180041
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.
To report the statistical analysis plan for the ANDROMEDA-SHOCK trial.
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.
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.
Abstract
Rev Bras Ter Intensiva. 2018;30(3):253-263
DOI 10.5935/0103-507X.20180041
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.
To report the statistical analysis plan for the ANDROMEDA-SHOCK trial.
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.
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.
Abstract
Rev Bras Ter Intensiva. 2014;26(3):269-276
DOI 10.5935/0103-507X.20140038
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.
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.
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.
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.
Abstract
Rev Bras Ter Intensiva. 2014;26(3):269-276
DOI 10.5935/0103-507X.20140038
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.
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.
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.
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.
