Vasopressin in vasoplegic shock in surgical patients: systematic review and meta-analysis

Purpose: Vasoplegia, or vasoplegic shock, is a syndrome whose main characteristic is reducing blood pressure in the presence of a standard or high cardiac output. For the treatment, vasopressors are recommended, and the most used is norepinephrine. However, new drugs have been evaluated, and conflicting results exist in the literature. Methods: This is a systematic review of the literature with meta-analysis, written according to the recommendations of the PRISMA report. The SCOPUS, PubMed, and ScienceDirect databases were used to select the scientific articles included in the study. Searches were conducted in December 2022 using the terms "vasopressin," "norepinephrine," "vasoplegic shock," "postoperative," and "surgery." Meta-analysis was performed using Review Manager (RevMan) 5.4. The endpoint associated with the study was efficiency in treating vasoplegic shock and reduced risk of death. Results: In total, 2,090 articles were retrieved; after applying the inclusion and exclusion criteria, ten studies were selected to compose the present review. We found no significant difference when assessing the outcome mortality comparing vasopressin versus norepinephrine (odds ratio = 1.60; confidence interval 0.47-5.50), nor when comparing studies on vasopressin versus placebo. When we analyzed the length of hospital stay compared to the use of vasopressin and norepinephrine, we identified a shorter length of hospital stay in cases that used vasopressin; however, the meta-analysis did not demonstrate statistical significance. Conclusions: Considering the outcomes included in our study, it is worth noting that most studies showed that using vasopressin was safe and can be considered in managing postoperative vasoplegic shock.

O Coração e a COVID-19: O que o Cardiologista Precisa Saber / The Heart and COVID-19: What Cardiologists Need to Know

Resumo Frente à pandemia da doença causada pelo novo coronavírus (COVID-19), o manejo do paciente com fator de risco e/ou doença cardiovascular é desafiador nos dias de hoje. As complicações cardiovasculares evidenciadas nos pacientes com COVID-19 resultam de vários mecanismos, que vão desde lesão direta pelo vírus até complicações secundárias à resposta inflamatória e trombótica desencadeada pela infecção. O cuidado adequado do paciente com COVID-19 exige atenção ao sistema cardiovascular em busca de melhores desfechos.

Abstract In face of the pandemic of the novel coronavirus disease 2019 (COVID-19), the management of patients with cardiovascular risk factors and/or disease is challenging. The cardiovascular complications evidenced in patients with COVID-19 derive from several mechanisms, ranging from direct viral injury to complications secondary to the inflammatory and thrombotic responses to the infection. The proper care of patients with COVID-19 requires special attention to the cardiovascular system aimed at better outcomes.

Estratégia liberal de transfusão de hemácias versus estratégia restritiva em pacientes submetidos à cirurgia oncológica: estudo controlado e randomizado / Liberal versus restrictive strategy of red blood cells transfusion in oncology surgery: a randomised controlled clinical trial

Objetivos: O propósito do estudo foi avaliar se uma estratégia restritiva de transfusão de hemácias era superior a uma estratégia liberal em reduzir a incidência de morte ou complicações graves em 30 dias em pacientes submetidos à cirurgia abdominal de grande porte para tratamento do câncer. Desenho: Estudo fase III de superioridade, unicêntrico, randomisado e controlado. Local: Unidade de Terapia Intensiva do Instituto do Câncer do Estado de São Paulo, Brasil. Participantes: Pacientes adultos com câncer submetidos à cirurgia abdominal de grande porte que necessitaram de cuidados pós-operatórios na unidade de terapia intesiva imediatamente após a cirurgia. Intervenção: Os pacientes foram aleatoriamente alocados durante a internação na unidade de terapia intensiva para uma estratégia liberal de transfusão de hemácias (eram transfundidos se a hemoglobina fosse inferior a 9 g/dL) ou para uma estratégia liberal (eram transfundidos se a hemoglobina fosse inferior a 7 g/dL). Desfecho primário: Desfecho composto de morte por qualquer causa ou complicações graves (cardiovasculares, síndrome do desconforto respiratório agudo, insuficiência renal com necessidade de diálise, choque séptico e reoperação) em 30 dias. Resultados: Foram incluídos 198 pacientes na análise final; 101 alocados no grupo restritivo e 97 no grupo liberal. A concentração de hemoblobina foi maior nos pacientes do grupo liberal durante o periodo do estudo. Também houve uma maior incidência de transfusão de hemácias neste grupo. O desfecho primário ocorreu em 19,6% (95% Intervalo de confiança [IC] 12,9 a 28,6) dos pacientes da estratégia liberal e em 35,6% (95% IC 27,0 a 45,4) dos pacientes da estratégia restrictiva (p= 0,012). Comparada com a estratégia restritiva, a estratégia liberal resultou em redução do risco absoluto do desfecho primário em 16% (95% IC 3,8 a 28,1) e um número necessário para tratar de 6,2 (95% IC 3,5 a 26,0). Conclusões: Uma estratégia liberal de...

Objectives: The purpose of this study was to evaluate whether a restrictive strategy of red blood cell (RBC) transfusion was superior to a liberal one for reducing mortality or severe clinical complications among patients undergoing major abdominal cancer surgery. Design: Phase III, randomised, unicentric, controlled, parallel-group, superiority trial. Setting: Intensive care unit (ICU) of Instituto do Cancer do Estado de Sao Paulo, Faculdade de Medicina da Universidade de Sao Paulo, a tertiary oncology university hospital in Sao Paulo, Brazil Participants: All adult patients with cancer who were undergoing major abdominal surgery requiring postoperative care in the ICU were included. Interventions: Patients were randomly allocated during intensive care unit stay to treatment with either a liberal RBC transfusion strategy (transfusion when haemoglobin concentration decreased below 9 g/dL) or a restrictive RBC transfusion strategy (transfusion when haemoglobin concentration decreased below 7 g/dL). Main outcome measures: The primary outcome was a composite endpoint of all cause mortality or severe complications (cardiovascular complications, acute respiratory distress syndrome, acute kidney injury requiring renal replacement therapy, septic shock and reoperation) at 30 days. Results: A total of 198 patients were included in the final analysis; 101 randomised to the restrictive group and 97 to the liberal group. Haemoglobin concentrations were higher during the study period in the liberal group with a greater use of RBC transfusions. The primary composite endpoint occurred in 19.6% (95% confidence interval [CI] 12.9 to 28.6) of patients in the liberal strategy group and in 35.6% (95%CI 27.0 to 45.4) of patients in the restrictive strategy group (p=.012). Compared to the restrictive strategy, the liberal transfusion strategy resulted in an absolute risk reduction for the composite outcome of 16% (95%CI 3.8 to 28.1) and a number needed to treat of 6.2...

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period.

Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results.

Lactate and base deficit are predictors of mortality in critically ill patients with cancer

OBJECTIVE: Cancer patients frequently require admission to intensive care unit. However, there are a few data regarding predictive factors for mortality in this group of patients. The aim of this study was to evaluate whether arterial lactate or standard base deficit on admission and after 24 hours can predict mortality for patients with cancer. METHODS: We evaluated 1,129 patients with severe sepsis, septic shock, or postoperative after high-risk surgery. Lactate and standard base deficit collected at admission and after 24 hours were compared between survivors and non-survivors. We evaluated whether these perfusion markers are independent predictors of mortality. RESULTS: There were 854 hospital survivors (76.5 percent). 24 h lactate .1.9 mmol/L and standard base deficit , -2.3 were independent predictors of intensive care unit mortality. 24 h lactate .1.9 mmol/L and 24 h standard base deficit , -2.3 mmol/Lwere independent predictors of hospital death. CONCLUSION: Our findings suggest that lactate and standard base deficit measurement should be included in the routine assessment of patients with cancer admitted to the intensive care unit with sepsis, septic shock or after highrisk surgery. These markers may be useful in the adequate allocation of resources in this population.