Postoperative Period of Myocardial Revascularization Surgery: Retrospective Cohort Study of a Single Center

ABSTRACT Introduction: Risk factors and postoperative complications can worsen the condition of patients undergoing coronary artery bypass grafting; some of these factors and complications are closely related to mortality rate. Objective: To describe clinical factors and outcomes related to mortality of patients undergoing coronary artery bypass grafting and on invasive mechanical ventilation. Methods: This is a single-center retrospective data analysis of patients who underwent coronary artery bypass grafting on invasive mechanical ventilation between 2013 and 2019. Data regarding clinical characteristics, postoperative complications, intensive care unit and mechanical ventilation time, and their relationship with mortality were analyzed. Results: Four hundred seventy-two patients who underwent coronary artery bypass grafting entered the study. Their mean age was 62.3 years, and mean body mass index was 27.3. The mortality rate was 4%. Fifty percent of the patients who had ventilator-associated pneumonia died. Considering the patients who underwent hemotherapy and hemodialysis, 20% and 33% died, respectively. Days of intensive care unit stay and high Acute Physiology and Chronic Health Evaluation score and Simplified Acute Physiology Score were significantly related to death. Conclusion: Factors and clinical conditions such as the patients' age, associated comorbidities, the occurrence of ventilator-associated pneumonia, length of stay in the intensive care unit, and mechanical ventilation time are related to higher mortality in patients undergoing coronary artery bypass grafting.

Capnografia volumétrica para monitoração respiratória de pacientes submetidos a colonoscopia diagnóstica com insuflação de ar comprimido e gás carbônico / Volumetric capnography for respiratory monitoring of patients during routine colonoscopy with room-air and carbon dioxide insufflation

ABSTRACT Background: Capnography and carbon dioxide (CO2) insufflation during gastrointestinal endoscopy under sedation are associated with safety and comfort improvements, respectively. Capnography can provide early detection of apnea and hypoxemia, whereas CO2 insufflation causes lower periprocedural discomfort. This is the first study to report the application of volumetric capnography in colonoscopy. Objective: This study aimed to evaluate the use of volumetric capnography with room air (RA) and CO2 insufflation during routine colonoscopy. Methods: In this prospective cohort study, 101 patients who underwent routine colonoscopy under sedation with volumetric capnography monitoring were included. Insufflation with RA was used to distend the intestinal lumen in group 1 (n=51), while group 2 (n=50) used CO2 insufflation. The primary endpoints were episodes of hypoxia, alveolar hypoventilation, and end-tidal CO2 (EtCO2). The secondary endpoints were tidal volume per minute, consumption of sedation medications, and post-procedure pain using the Gloucester modified pain scale. Results: The number of episodes of hypoxia (SpO2<90%) was similar between the groups: four episodes in Group 1 and two episodes in Group 2. The duration of hypoxia was significantly longer in group 2 (P=0.02). Hypoalveolar ventilation (EtCO2) occurred more frequently in Group 2 than in Group 1 (27 vs 18 episodes, P=0.05). Regarding EtCO2, Group 2 showed higher values in cecal evaluation (28.94±4.68 mmHg vs 26.65±6.12 mmHg, P=0.04). Regarding tidal volume per minute, Group 2 had significantly lower values at the cecal interval compared to Group 1 (2027.53±2818.89 vs 970.88±1840.25 L/min, P=0.009). No episodes of hypercapnia (EtCO2 > 60 mmHg) occurred during the study. There was no difference in the consumption of sedation medications between the groups. Immediately after colonoscopy, Group 2 reported significantly less pain than Group 1 (P=0.05). Conclusion: In our study, volumetric capnography during colonoscopy was feasible and effective for monitoring ventilatory parameters and detecting respiratory complications. CO2 insufflation was safe and associated with less pain immediately after colonoscopy.

RESUMO Contexto: A capnografia e a insuflação de gás carbônico (CO2) durante endoscopia digestiva sob sedação são associados à maior segurança e conforto do paciente, respectivamente. A capnografia pode detectar precocemente a apneia e hipoxemia, enquanto a insuflação de CO2 causa menor desconforto periprocedimento. Relatos da aplicação da capnografia volumétrica em colonoscopias são escassos. Objetivo: Avaliar o uso de capnograifa volumétrica durante colonoscopia diagnóstica com insuflação de ar comprimido e CO2. Métodos: Em estudo prospectivo de coorte, foram incluídos um total de 101 pacientes submetidos a colonoscopia diagnóstica sob sedação com monitoração respiratória por meio de capnografia volumétrica. Insuflação com ar comprimido foi usado para distender o lúmen intestinal no Grupo 1 (n=51), enquanto o Grupo 2 (n=50) utilizou CO2 para insuflação. Objetivos primários foram avaliar episódios de hipóxia, hipoventilação alveolar e CO2 expirado (EtCO2). Objetivos secundários foram avaliar o volume alveolar por minuto, consumo de sedativos e a dor pós-colonoscopia por meio da Escala de Dor Modificada de Gloucester. Resultados: O número de episódios de hipóxia (SpO2 <90%) foi semelhante entre os grupos: quatro episódios no Grupo 1 e dois episódios no Grupo 2. A duração da hipóxia foi significativamente maior no Grupo 2 (P=0,02). A hipoventilação alveolar (EtCO2 ≥25% do valor basal) ocorreu mais frequentemente no Grupo 2 quando comparado ao Grupo 1 (27 vs 18 episódios, P=0,05). Em relação ao EtCO2, o Grupo 2 apresentou valores maiores no momento de aferição cecal (28.94±4.68 vs 26.65±6.12 mmHg, P=0,04). Quanto ao volume alveolar por minuto, o Grupo 2 apresentou valores significativamente menores no momento de aferição cecal quando comparado ao Grupo 1 (2027.53±2818.89 vs 970.88±1840.25 L/min, P=0,009). Não houve ocorrência de hipercapnia durante o estudo (EtCO2 >60 mmHg). Não houve diferença em relação ao consumo de sedativos entre os dois grupos. Imediatamente após a colonoscopia, o Grupo 2 apresentou significativamente menos dor que o Grupo 1 (P=0,05). Conclusão: Em nosso estudo, a capnografia volumétrica durante colonoscopia foi factível e eficaz para monitorar parâmetros ventilatórios e detectar complicações respiratórias, e a insuflação com CO2 foi segura e associada a menor dor imediatamente pós-colonoscopia.

Effects of home-based inspiratory muscle training on sickle cell disease (SCD) patients

ABSTRACT Introduction: Inspiratory muscle training (IMT) has been shown to be an efficient method of improving exercise tolerance and inspiratory and expiratory muscle strength in several diseases. The effects of IMT on patients with sickle cell anemia (SCD) are relatively unknown. Our study aimed to evaluate the effects of IMT on adult SCD patients, regarding respiratory muscle strength (RMS) variables, lung function, exercise tolerance, blood lactation concentration, limitation imposed by dyspnea during daily activities and impact of fatigue on the quality of life. Methods: This was a randomized single-blind study, with an IMT design comprising true load (TG) and sham load (SG) groups. Initial assessment included spirometry, volumetric capnography (VCap) and measurement of RMS by maximal inspiratory and expiratory pressure (PImax and PEmax). The Medical Research Council dyspnea scale and modified fatigue impact scale were also applied and blood lactate concentration was measured before and after the 6-minute walk test. After this initial assessment, the patient used the IMT device at home daily, returning every 6 weeks for RMS reassessment. Both groups used the same device and were unaware of which group they were in. After a period totaling 18 weeks, patients underwent the final evaluation, as initially performed. Results: Twenty-five patients in total participated until the end of the study (median age 42 years). There were no significant differences between TG and SG based on age, sex, body mass index or severity of genotype. At the end of the training, both groups showed a significant increase in PEmax and PImax, improvement in Vcap and in exercise tolerance and dyspnea reduction while performing daily life activities. The same was observed in patients grouped according to disease severity (HbSS and HbSβ0 vs HbSC and HbSβ+), without differences between groups. Conclusion: Home-based inspiratory muscle training benefits outpatients with SCD, including the sham load group. Trial registration:http://www.ensaiosclinicos.gov.br; registration number: RBR-6g8n92.

Lung function and stress echocardiography in pulmonary arterial hypertension: a cross-sectional study

ABSTRACT BACKGROUND: The mechanism of exercise limitation in idiopathic pulmonary arterial hypertension (IPAH) is not fully understood. The role of hemodynamic alterations is well recognized, but mechanical, ventilatory and gasometric factors may also contribute to reduction of exercise capacity in these individuals. OBJECTIVE: To investigate whether there is an association between ventilatory pattern and stress Doppler echocardiography (SDE) variables in IPAH patients. DESIGN AND SETTING: Single-center prospective study conducted in a Brazilian university hospital. METHODS: We included 14 stable IPAH patients and 14 age and sex-matched controls. Volumetric capnography (VCap), spirometry, six-minute walk test and SDE were performed on both the patients and the control subjects. Arterial blood gases were collected only from the patients. The IPAH patients and control subjects were compared with regard to the abovementioned variables. RESULTS: The mean age of the patients was 38.4 years, and 78.6% were women. The patients showed hypocapnia, and in spirometry 42.9% presented forced vital capacity (FVC) below the lower limit of normality. In VCap, IPAH patients had higher respiratory rates (RR) and lower elimination of CO2 in each breath. There was a significant correlation between reduced FVC and the magnitude of increases in tricuspid regurgitation velocity (TRV). In IPAH patients, VCap showed similar tidal volumes and a higher RR, which at least partially explained the hypocapnia. CONCLUSIONS: The patients with IPAH showed hypocapnia, probably related to their higher respiratory rate with preserved tidal volumes; FVC was reduced and this reduction was positively correlated with cardiac output.

O espectro clínico e laboratorial da doença de Alzheimer: uma perspectiva neurológica / The clinical and laboratory spectrum of Alzheimer's disease: a neurological perspective / El espectro clínico y de laboratorio de la enfermedad de Alzheimer: una perspectiva neurológica

Esta revisão da literatura tem como objetivo mostrar recentes mudanças relacionadas ao diagnóstico da doença de Alzheimer (DA). O diagnóstico permanece clínico, no entanto, há um entendimento crescente de que biomarcadores específicos no líquido cefalorraquidiano e na neuroimagem molecular possam desempenhar um papel importante na definição etiopatogênica da doença. Os biomarcadores podem ser importantes para o diagnóstico nos estágios iniciais da DA. Considerando que a DA seja um processo fisiopatológico cerebral, a presença de biomarcadores específicos indica o diagnóstico de DA. Atualmente, o uso de biomarcadores é direcionado para pesquisa clínica e para o desenvolvimento de novas drogas.

This narrative review of the literature aims to show the most recent changes related to the diagnosis of Alzheimer's disease (AD). The diagnosis remains clinical, however, there is a growing understanding that specific biomarkers in cerebrospinal fluid and molecular neuroimaging may play an important role in the etiopathogenic definition of the disease. Biomarkers may be particularly important for the diagnosis in the early stages of AD. Considering that AD is a brain pathophysiological process, the presence of AD biomarkers indicates the diagnosis of AD. Currently, the use of biomarkers is directed towards clinical research and the development of new drugs.

Esta revisión narrativa de la literatura tiene como objetivo mostrar los cambios recientes relacionados con el diagnóstico de la enfermedad de Alzheimer (EA). El diagnóstico es clínico, sin embargo, existe una creciente comprensión de que los biomarcadores en el líquido cefalorraquídeo y neuroimagen molecular pueden desempeñar un papel importante en la definición etiopatogénica. Los biomarcadores pueden ser importantes para el diagnóstico en las primeras etapas de la EA. Reconociendo que la EA es un proceso fisiopatológico cerebral, la presencia de biomarcadores indica EA. Actualmente, el uso de biomarcadores está dirigido a la investigación clínica y al desarrollo de nuevos fármacos.

Análise da capacidade funcional pelo Six Minute Walk Test (6MWT) em doentes renais crônicos / Functional capacity analysis using the Six Minute Walk Test (6MWT) in chronic renal patients

A doença renal crônica (DRC) é caracterizada por alterações na função ou estrutura renal durante 3 meses ou mais, levando a perda funcional dos rins e a diminuição da capacidade funcional. OBJETIVO: Avaliar a capacidade física de pacientes doentes renais crônicos no estagiamento 5, através do six minute walk test (6MWT), e comparar a distância percorrida e prevista de acordo o gênero. MÉTODOS: Trata-se de um estudo transversal, de caráter analítico descritivo. Foram incluídos indivíduos com DRC no estagiamento 5, de 18 a 59 anos, de ambos os gêneros e excluídos pacientes com deformidades em membros inferiores, tabagistas, etilistas e com doença pulmonar obstrutiva crônica. Os participantes foram submetidos ao six minute walk test. Foram realizados os cálculos de média e desvio padrão, os testes de Pearson e T-student, respeitando o valor de significância < 0,05 para análise estatística através do software SPSS 20.0 para Windows. RESULTADOS: Dos 139 pacientes em hemodiálise, 30 foram elegíveis, sendo que destes 12 (doze) eram do gênero feminino e 18 (dezoito) do gênero masculino, com idade média em anos de 42,33±15,58 e 39,27±12,22. A distância prevista em metros para o gênero feminino foi de 763,10±63,62 e gênero masculino 840,82±52,42. A média de distância percorrida pelo gênero feminino foi de 325,33±78,31 (r=0,1, p=0,00), do gênero masculino 389,67±95,80 metros (r=0,98, p=0,00). CONCLUSÃO: Indivíduos renais crônicos no estagiamento 5, apresentam desempenho inferior ao previsto de acordo com a distância prevista e percorrida através 6MWT independente do gênero, indicando uma menor capacidade funcional desta população.

Chronic kidney disease (CKD) is characterized by changes in kidney function or structure for 3 months or more, leading to functional loss of the kidneys and decreased functional capacity. OBJECTIVE: To evaluate the physical capacity of patients with chronic kidney disease during stage 5, using the six minute walk test (6MWT), and to compare the distance covered and predicted according to gender. METHODS: This is a cross-sectional, descriptive analytical study. Individuals with CKD were included in stage 5, aged 18 to 59 years, of both genders and patients with lower limb deformities, smokers, alcoholics and chronic obstructive pulmonary disease were excluded. Participants underwent the six minute walk test. Mean and standard deviation calculations were performed, as well as the Pearson and T-student tests, respecting the significance value <0.05 for statistical analysis using the SPSS 20.0 software for Windows. RESULTS: Of the 139 patients on hemodialysis, 30 were eligible, of which 12 (twelve) were female and 18 (eighteen) male, with a mean age in years old of 42.33 ± 15.58 and 39.27 ± 12, 22. The predicted distance in meters for females 763.10 ± 63.62 and males 840.82 ± 52.42. The average distance covered by the female gender was 325.33 ± 78.31 (r = 0.1, p = 0.00), male 389.67 ± 95.80 meters (r = 0.98, p = 0.00). CONCLUSION: Chronic renal individuals undergoing staging 5, perform less than expected according to the predicted distance and traveled through 6MWT regardless of gender, indicating a lower functional capacity of this population.

Model of single-sized endotracheal tube for adults / Modelo de tubo endotraqueal de tamanho único para adultos

ABSTRACT Objective To simulate different diameters of endotracheal tubes and to verify the fluid dynamics aspects by means of flow and resistance measurements. Methods Fluid dynamics software was used to calculate mean flow and airway resistance in endotracheal tube with a diameter of 6.0, 7.0, 7.5, 8.0, 9.0 and 10.0mm at normal body temperature and under constant pressure. The same measurements were taken in the fusion of the first 22cm of a 9.0mm endotracheal tube with 10.0mm diameter, and with the end part in 12cm of a 6.0mm endotracheal tube with 7.0mm diameter. Results The fusion of the first 22cm of an endotracheal tube of 10.0mm diameter with the terminal part in 12cm of an endotracheal tube of 6.0mm diameter, preserving the total length of 34cm, generated average flow and airway resistance similar to that of a conventional 7.5mm endotracheal tube. Conclusion This simulation study demonstrates that a single-sized endotracheal tube may facilitate endotracheal intubation without causing increased airway resistance.

RESUMO Objetivo Simular diferentes diâmetros de tubos endotraqueais e verificar os aspectos fluidinâmicos, considerando medições de fluxo e resistência. Métodos Foi utilizado um software de fluidinâmica para calcular o fluxo médio e a resistência das vias aéreas nos tubos endotraqueais com diâmetro de 6,0, 7,0, 7,5, 8,0, 9,0 e 10,0mm, em temperatura corporal normal e pressão constante. As mesmas medidas foram realizadas na fusão dos primeiros 22cm de um tubo endotraqueal de 9,0 e 10,0mm de diâmetro, com a parte terminal em 12cm de um tubo endotraqueal de 6,0 e 7,0mm de diâmetro. Resultados A fusão dos primeiros 22cm de um tubo endotraqueal de diâmetro 10,0 mm com a parte terminal em 12cm de um tubo endotraqueal de 6,0mm de diâmetro, preservando o comprimento total de 34cm, gerou fluxo médio e resistência de vias aéreas semelhantes aos de um tubo endotraqueal convencional de 7,5mm. Conclusão Um tubo endotraqueal de tamanho único pode facilitar a intubação endotraqueal, sem causar aumento de resistência na via aérea.

Respiratory evaluation through volumetric capnography among grade III obese and eutrophic individuals: a comparative study

ABSTRACT BACKGROUND: Excess trunk body fat in obese individuals influences respiratory physiological function. The aims of this study were to compare volumetric capnography findings (VCap) between severely obese patients and normal-weight subjects and to assess whether there is any association between neck circumference (NC), waist-hip ratio (WHR) and VCap among grade III obese individuals. DESIGN AND SETTING: Analytical observational case-matched cross-sectional study, University of Campinas. METHODS: This cross-sectional study compared VCap variables between 60 stage III obese patients and 60 normal-weight individuals. RESULTS: In comparison with the normal-weight group, obese patients presented higher alveolar minute volume (8.92 ± 4.94 versus 6.09 ± 2.2; P = < 0.0001), CO2 production (278 ± 91.0 versus 209 ± 60.23; P < 0.0001), expiratory tidal volume (807 ± 365 versus 624 ± 202; P = 0.005), CO2 production per breath (21.1 ± 9.7 versus 16.7 ± 6.16; P = 0.010) and peak expiratory flow (30.9 ± 11.9 versus 25.5 ± 9.13; P = 0.004). The end-expiratory CO2 (PetCO2) concentration (33.5 ± 4.88 versus 35.9 ± 3.79; P = 0.013) and the phase 3 slope were normalized according to expired tidal volume (0.02 ± 0.05 versus 0.03 ± 0.01; P = 0.049) were lower in the obese group. CONCLUSIONS: The greater the NC was, the larger were the alveolar minute volume, anatomical dead space, CO2 production per minute and per breath and expiratory volume; whereas the smaller were the phase 2 slope (P2Slp), phase 3 slope (P3Slp) and pressure drop in the mouth during inspiration.

Can musical intervention improve memory in Alzheimer's patients? Evidence from a systematic review / Intervenção musical pode melhorar a memória em pacientes com doença de Alzheimer? Uma revisão sistemática

ABSTRACT Treatment with music has shown effectiveness in the treatment of general behavioural and cognitive symptoms of patients with various types of dementia. Objective: To assess the effectiveness of treatment with music on the memory of patients with Alzheimer's disease (AD). Methods: A systematic search was performed on PubMed (Medline), Cochrane Library, PsycINFO and Lilacs databases up to June 2017 and included all randomized controlled trials that assessed memory using musical interventions in patients with AD. Results: Forty-two studies were identified, and 24 studies were selected. After applying the exclusion criteria, four studies involving 179 patients were included. These studies showed the benefits of using music to treat memory deficit in patients with AD. Conclusion: To the best of our knowledge, this is the first systematic review focusing on randomized trials found in the literature that analysed the role of musical interventions specifically in the memory of patients with AD. Despite the positive outcome of this review, the available evidence remains inconsistent due to the small number of randomized controlled trials.

RESUMO O tratamento com música vem demonstrando eficácia no tratamento de sintomas comportamentais e cognitivos gerais de pacientes com vários tipos de demência. Objetivo: Avaliar a eficácia do tratamento com música para a memória de pacientes com doença de Alzheimer (DA). Métodos: Foi realizada uma revisão sistemática nos bancos de dados PubMed (Medline), Cochrane Library, PsycINFO e Lilacs até junho de 2017 que incluiu todos os ensaios clínicos randomizados controlados usando intervenções musicais em pacientes com DA e que avaliaram a memória. Resultados: Foram encontrados 42 estudos sendo selecionados 24 estudos completos. Após a aplicação dos critérios de exclusão, foram incluídos quatro estudos envolvendo 179 pacientes. Esses estudos mostraram os benefícios do uso da música para tratar o déficit de memória em pacientes com DA. Conclusão: Até o momento, este é o primeiro estudo de revisão sistemática que utilizou ensaios clínicos randomizados da literatura que analisou o papel das intervenções musicais especificamente na memória de pacientes com DA. Apesar do resultado positivo desta revisão, a evidência disponível permanece frágil devido ao pequeno número de ensaios clínicos randomizados.

A fatal and metabolic experimental hemorrhagic shock in immature swine

Abstract Purpose: To use blood lactate (BL) as an end-point metabolic marker for the begin resuscitation of volume replacement in experimental hemorrhagic shock. Methods: Group I (n=7) was not bled (Control). Animals in Group II (n=7) were bled to a MAP of 30mmHg in thirty minutes. Hemodynamic and metabolic data were recorded at Baseline, at 30, 60 and 120 minutes after Baseline. The animals were intubated in spontaneous breathing (FIO2=0.21) with halothane. Results: Group I all survived. In Group II all died; no mortality occurred before a BL<10mM/L. Beyond the end-point all animals exhibited severe acidemia, hyperventilation and clinical signs of shock. Without treatment all animals died within 70.43±24.51 min of hypotension shortly after reaching an average level of BL 17.01±3.20mM/L. Conclusions: Swine's breathing room air spontaneously in hemorrhagic shock not treated a blood lactate over 10mM/L results fatal. The predictable outcome of this shock model is expected to produce consistent information based on possible different metabolic and hemodynamic patterns as far as the type of fluid and the timing of resuscitation in near fatal hemorrhagic shock.

Evaluation of the Efficiency of the Atraumatic Endotracheal Tube in the Pulmonary-Gas Exchange: an Experimental Study

ABSTRACT OBJECTIVE: Mechanical ventilation is frequently necessary, in which case the use of an endotracheal tube is mandatory. The tube has an inflatable balloon in its distal extremity, whose aim is, among other functions, an efficient arterialization. However, serious injuries in the place of contact of the balloon with the trachea can be frequent. Some studies point out that balloons with permanent pressure may reduce this complication. Nevertheless, air scape, expressed by the inspiratory (IV) and expiratory volume (EV) variation (Δ IV-EV), may occur, possibly leading to hypoxemia. Thus, the goal of this study was to verify the efficiency of a modified endotracheal tube on arterializations compared to the traditional endotracheal tube. METHODS: The modified endotracheal tube presents intermittent insufflation, with three drillings in the internal region of the cuff, allowing for insufflation in the inspiratory phase of the mechanical ventilation. Three animals were used for the control group, with a cuff pressure of 30 cmH2O, and seven pigs had the modified endotracheal tube. Each animal was kept under mechanical ventilation (FIO2=0.21) for 6 hours. Arterial and venous gases were measured every three hours (T0; T3; T6). RESULTS: The gases confirmed the lack of hypoxia between the Groups, with a difference in the ΔIV-EV at T0 (P=0.0486). CONCLUSIONS: In this study, the lack of hypoxia showed the efficiency of the modified endotracheal tube. However, new studies are necessary, particularly in diseased lungs, in order to evaluate the real efficiency of the mentioned device on the pulmonary gas exchange.

Adjustable inspiratory occlusion valve in experimental bronchopleural fistula. A new therapeutic perspective

PURPOSE: To assess the efficacy of an adjustable inspiratory occlusion valve in experimental bronchopleural fistula during mechanical ventilation.METHODS:We studied six mechanically ventilated pigs in a surgically created, reproducible model of bronchopleural fistula managed with mechanical ventilation and water-sealed thoracic drainage. An adjustable inspiratory occlusion valve was placed between the thoracic drain and the endotracheal tube. Hemodynamic data, capnography and blood gases were recorded before and after the creation of the bronchopleural fistula as well as after every adjustment of the inspiratory occlusion valve.RESULTS:When compared with the standard water-sealed drainage treatment, the use of an adjustable inspiratory occlusion valve improved the alveolar tidal volume and reduced bronchopleural air leak (p<0.001), without hemodynamic compromise when compared with conventional water sealed drainage.CONCLUSION: The use of an adjustable inspiratory occlusion valve improved the alveolar tidal volume, reduced alveolar leak, in an experimental reproducible model of bronchopleural fistula, without causing any hemodynamic derangements when compared with conventional water sealed drainage.

O desregramento do gozo e a legitimação do gozo sexual: novos modos de funcionamento das mulheres e mães / The disruption of the jouissance and the legitimation of the sexual jouissance: new ways of functioning of women and mothers

O artigo se constrói a partir de abordagem de certos de modos de funcionamento de mães e mulheres, nessa realidade social marcada pela crescente influência do discurso do capitalista no discurso da ciência. Nessa civilização que prima pelo mais-de-gozar, o sistema favorece certas formas típicas de vivenciar a posição feminina e materna, novas formas de laços sociais, de parcerias sexuadas e, como se tem dito, novas manifestações sintomáticas. O percurso escolhido circunscreve, portanto, pontos cruciais desse sistema discursivo que conta com suas formas singulares de repartição sistematizada de meios e maneiras de gozar. Ele passa por demarcações próprias da condição do feminino, chegando a um fragmento de caso, paradigmático da posição mulher-mãe como sujeito suposto saber do ser pai, juízas do pai para seus filhos.

This paper examines some ways of functioning of mothers and women in a society marked by the growing influence of the capitalist discourse in the discourse of science. In a civilization marked by the plus de jouir , some typical ways of living the position of women and mothers are primed, just as new forms of social ties and sexual partnerships - as it is usually said, new symptomatic manifestations. Some crucial points in this discourse are highlighted, with its particular partitions of ways of the jouissance , and we examine a paradigmatic case of the position of mother-woman.

Risk factors for transient dysfunction of gas exchange after cardiac surgery / Fatores de risco para disfunção transitória da troca gasosa após a cirurgia cardíaca

Objective: A retrospective cohort study was preformed aiming to verify the presence of transient dysfunction of gas exchange in the postoperative period of cardiac surgery and determine if this disorder is linked to cardiorespiratory events. Methods: We included 942 consecutive patients undergoing cardiac surgery and cardiac procedures who were referred to the Intensive Care Unit between June 2007 and November 2011. Results: Fifteen patients had acute respiratory distress syndrome (2%), 199 (27.75%) had mild transient dysfunction of gas exchange, 402 (56.1%) had moderate transient dysfunction of gas exchange, and 39 (5.4%) had severe transient dysfunction of gas exchange. Hypertension and cardiogenic shock were associated with the emergence of moderate transient dysfunction of gas exchange postoperatively (P=0.02 and P=0.019, respectively) and were risk factors for this dysfunction (P=0.0023 and P=0.0017, respectively). Diabetes mellitus was also a risk factor for transient dysfunction of gas exchange (P=0.03). Pneumonia was present in 8.9% of cases and correlated with the presence of moderate transient dysfunction of gas exchange (P=0.001). Severe transient dysfunction of gas exchange was associated with patients who had renal replacement therapy (P=0.0005), hemotherapy (P=0.0001), enteral nutrition (P=0.0012), or cardiac arrhythmia (P=0.0451). Conclusion: Preoperative hypertension and cardiogenic shock were associated with the occurrence of postoperative transient dysfunction of gas exchange. The preoperative risk factors included hypertension, cardiogenic shock, and diabetes. Postoperatively, pneumonia, ventilator-associated pneumonia, renal replacement therapy, hemotherapy, and cardiac arrhythmia were associated with the appearance of some degree of transient dysfunction of gas exchange, which was a risk factor for reintubation, pneumonia, ventilator-associated pneumonia, and renal replacement therapy in the postoperative period ...

Objetivo: Estudo de coorte retrospectivo com objetivo de verificar a presença de disfunção transitória da troca gasosa no pós-operatório de cirurgia cardíaca e determinar se esse transtorno está relacionado a eventos cardiorrespiratórios. Métodos: Foram incluídos 942 pacientes consecutivos submetidos à cirurgia cardíaca e procedimentos cardíacos, encaminhados para a Unidade de Terapia Intensiva, entre junho de 2007 e novembro de 2011. Resultados: A síndrome do desconforto respiratório agudo foi observada em 15 (2%) pacientes, 199 (27,75%) pacientes apresentaram disfunção transitória da troca gasosa leve, disfunção transitória da troca gasosa moderada foi observada em 402 (56,1%) pacientes e disfunção transitória da troca gasosa grave em 39 (5,4%). A presença de hipertensão arterial sistêmica e choque cardiogênico foi associada ao surgimento de disfunção transitória da troca gasosa moderada no período pós-operatório (P=0,02 e P=0,019, respectivamente) e foram considerados fatores de risco para essa disfunção (P=0,0023 e P=0,0017, respectivamente). A presença de diabetes mellitus também foi considerada um fator de risco para disfunção transitória da troca gasosa (P=0,03). Houve correlação entre a presença de pneumonia e a presença de disfunção transitória da troca gasosa moderada em 8,9% dos casos (P=0,001). A presença de disfunção transitória da troca gasosa grave foi associada a pacientes que necessitaram de hemodiálise (P=0,0005), hemoterapia (P=0,0001), nutrição enteral (P=0,0012), ou arritmia cardíaca (P=0,0451). Conclusão: A presença de hipertensão arterial sistêmica pré-operatória e choque cardiogênico foi associada à ocorrência de disfunção transitória da troca gasosa pós-operatória. Os fatores de risco pré-operatórios foram hipertensão arterial sistêmica, choque cardiogênico e diabetes. No pós-operatório, pneumonia, pneumonia associada à ventilação, hemodiálise, hemoterapia e arritmia cardíaca foram associadas com certo grau de ...

Hemodynamic, ventilatory and gasometric evaluation of an experimental bronchopleural fistula

PURPOSE: To investigate the hemodynamic and ventilatory changes associated with the creation of an experimental bronchopleural fistula (BPF) treated by mechanical ventilation and thoracic drainage with or without a water seal. METHODS : Six large white pigs weighing 25 kg each which, after general anesthesia, underwent endotracheal intubation (6mm), and mechanically ventilation. Through a left thoracotomy, a resection of the lingula was performed in order to create a BPF with an output exceeding 50% of the inspired volume. The chest cavity was closed and drained into the water sealed system for initial observation of the high output BPF. RESULTS: Significant reduction in BPF output and PaCO2 was related after insertion of a water-sealed thoracic drain, p< 0.05. CONCLUSION: Insertion of a water-sealed thoracic drain resulted in reduction in bronchopleural fistula output and better CO2 clearance without any drop in cardiac output or significant changes in mean arterial pressure. .

Effectiveness of the endotracheal tube cuff on the trachea: physical and mechanical aspects / Eficácia do balonete do tubo endotraqueal sobre a traqueia: aspectos físicos e mecânicos

Introduction: The inflation pressure of the endotracheal tube cuff can cause ischemia of the tracheal mucosa at high pressures; thus, it can cause important tracheal morbidity and tracheal microaspiration of the oropharyngeal secretion, or it can even cause pneumonia associated with mechanical ventilation if the pressure of the cuff is insufficient. Objective: In order to investigate the effectiveness of the RUSCH® 7.5 mm endotracheal tube cuff, this study was designed to investigate the physical and mechanical aspects of the cuff in contact with the trachea. Methods: For this end, we developed an in vitro experimental model to assess the flow of dye (methylene blue) by the inflated cuff on the wall of the artificial material. We also designed an in vivo study with 12 Large White pigs under endotracheal intubation. We instilled the same dye in the oral cavity of the animals, and we analyzed the presence or not of leakage in the trachea after the region of the cuff after their deaths (animal sacrifice). All cuffs were inflated at the pressure of 30 cmH2O. Results: We observed the passage of fluids through the cuff in all in vitro and in vivo experimental models. Conclusion: We conclude that, as well as several other cuff models in the literature, the RUSCH® 7.5 mm tube cuffs are also not able to completely seal the trachea and thus prevent aspiration of oropharyngeal secretions. Other prevention measures should be taken. .

Introdução: A pressão de insuflação do balonete (cuff) do tubo endotraqueal tanto pode causar isquemia de mucosa traqueal em pressões elevadas, e assim ocasionar morbidade traqueal importante, quanto pode causar microaspiração traqueal de secreção de orofaringe ou, ainda, ocasionar pneumonia associada à ventilação mecânica, caso a pressão do balonete seja insuficiente. Objetivo: A fim de investigar a eficácia do balonete do tubo endotraqueal RUSCH® 7,5mm, este estudo foi desenhado para investigar aspectos físicos e mecânicos do balonete em contato com a traqueia. Métodos: Para isto, foi desenvolvido modelo experimental in vitro para avaliar o escoamento de corante (azul de metileno) pelo balonete insuflado na parede de material artificial. Também foi desenhado estudo in vivo com 12 porcos da raça Large-White sob intubação endotraqueal. Foi instilado o mesmo corante na cavidade oral do animal e após óbito (sacrifício do animal) foi analisada a presença ou não de vazamento deste na traqueia pós-região do balonete. Todos os balonetes foram insuflados na pressão de 30 cmH2O. Resultados: Houve passagem de fluidos pelo balonete em todos os modelos experimentais in vitro e in vivo. Conclusão: Podemos concluir que, assim como diversos outros modelos de balonetes na literatura, balonetes do tubo RUSCH® 7,5mm também não são capazes de vedar completamente a traqueia e com isso prevenir aspiração de secreções orofaríngeas. Outras medidas para a prevenção devem ser tomadas. .

Avaliação do comprometimento respiratório em pacientes com lúpus eritematoso sistêmico com o teste de caminhada de seis minutos / Evaluation of respiratory impairment in patients with systemic lupus erythematosus with the six-minute walk test

Objetivo: Avaliar pacientes com LES estável, sem comprometimento respiratório evidente, por meio do TC6M. Casuística e métodos: Foram recrutados 45 pacientes com LES estável. Foi utilizado o protocolo ATS/ERS para TC6M, tendo sido escolhidos dois parâmetros com pontos de corte. Resultados: Quarenta e dois dos pacientes eram mulheres.A média de idade foi 39 ± 11,4 anos; a duração média da doença, 121 ± 93,1 meses; valor médio de MRC 2 ± 0; CVF média 85,9 ± 34,2%; VEF1 médio 67,5 ± 21,6%; PIM média 82 ± 58,4%; PEM média 78 ± 37,3%; frequência cardíaca média em repouso 75 ± 12,8 bpm; frequência respiratória média em repouso 19 ± 5,3 bpm; distância média no TC6M 478 ± 82 m; SpO2 média em repouso 98 ± 0,8%; queda média em SpO2 4 ± 6 pontos. Quando a população em estudo foi dividida de acordo com o valor de corte de 400 m de distância caminhada, a frequência cardíaca imediatamente antes do teste foi significativamente menor naqueles participantes que caminharam menos de 400 m (p = 0,0043), da mesma forma que o valor da escala de Borg (p = 0,0036). De acordo com a presença de saturação ≥ 4, a frequência cardíaca ao final do teste estava significativamente mais elevada naqueles participantes exibindo dessaturação (p = 0,0170); PEM (p = 0,0282) e TC6M (p = 0,0291) estavam significativamente menores e PIM revelou uma tendência para diminuir (p = 0,0504). CVF < limite inferior do normal foi achado significativamente associado com o grupo com dessaturação (p = 0,0274). Conclusão: Comparado com TC6M, a dessaturação foi o indicador mais apropriado para localizar os pacientes com os índices mais comprometidos nos testes de função respiratória. .

Objective: Evaluate SLE stable patients, without overt respiratory compromise, by means of 6MWT. Casuistic and methods: Forty-five stable SLE patients were enrolled. The ATS/ERS protocol for 6MWT, was used and two parameters with cut-off points were chosen. Results: Forty-two patients were women. The mean age was 39 ± 11.4 years; mean duration of disease, 121 ± 93.1 months; mean value of MRC, 2 ± 0; mean FVC, 85.9 ± 34.2%; mean FEV1, 67.5 ± 21.6%; mean MIP, 82 ± 58.4%; mean MEP, 78 ± 37.3%; mean heart rate at rest, 75 ± 12.8 bpm; mean respiratory rate at rest, 19 ± 5.3 bpm; mean 6MWD, 478 ± 82 m; mean SpO2 at rest was 98 ± 0.8%; mean fall in SpO2, 4 ± 6 points. When the study population was divided according to the 400-m walk distance cut-off value, the heart rate immediately before the test was significant lower in those participants who walked less than 400 m (p = 0.0043), just like the value of Borg scale (p = 0.0036); according to the presence of saturation ≥ 4, heart rate at the end of the test was significantly higher in those participants who were showing desaturation (p = 0.0170); MEP (p = 0.0282) and 6MWD (p = 0.0291) were significantly lower, and MIP showed a tendency towards being smaller (p = 0.0504). FVC < normal inferior limit was significantly associated with the group with desaturation (p = 0.0274). Conclusion: Compared to 6MWD, desaturation was better suited to find the patients with the most compromised indexes in respiratory function tests. .