Pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus ® ) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy / Análise do contorno do pulso calibrado por termodiluição transpulmonar (Picco Plus ® ) para o manejo perioperatório de cesariana em paciente com miocardiopatia grave

ABSTRACT BACKGROUND: The delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality. OBJECTIVE: To describe the use of pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus® for the perioperative management of a caesarean section in a patient with severe cardiomyopathy. CASE REPORT: We describe the case of a 28-year-old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra- and post-operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus® monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs. CONCLUSION: This case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future.

RESUMO JUSTIFICATIVA: O parto em pacientes cardíacas é um desafio para o anestesiologista, para o qual o bem-estar tanto da mãe quanto do feto é a questão principal. Em caso de cesariana, o monitoramento avançado permite melhorar a condição hemodinâmica e diminuir a morbidade e mortalidade. OBJETIVO: Descrever o uso da análise do contorno do pulso calibrado por termodiluição transpulmonar (Picco Plus®) para o manejo perioperatório de cesariana em paciente com miocardiopatia grave. RELATO DE CASO: Descrevemos o caso de uma paciente de 28 anos com uma doença cardíaca congênita, submetida a uma cesariana sob anestesia geral devido a afecção materna e apresentação fetal pélvica. O manejo nos períodos intraoperatório e pós-operatório foi aprimorado por monitoração hemodinâmica avançada obtida pela análise do contorno da onda de pulso e calibração por termodiluição (monitor Picco Plus®). As informações sobre pré-carga, pós-carga e contratilidade miocárdica foram úteis para orientar a reposição hídrica e o uso de medicamentos vasoativos. CONCLUSÃO: Este relato de caso ilustra a importância da monitoração hemodinâmica avançada com dispositivo aceitavelmente invasivo em pacientes obstétricas com alto risco cardíaco. O aumento do conhecimento no manejo hemodinâmico avançado provavelmente possibilitará a redução da morbidade e mortalidade de pacientes obstétricas no futuro.

Early Cardiac Function Monitoring for Detection of Subclinical Doxorubicin Cardiotoxicity in Young Adult Patients with Breast Cancer / 한국유방암학회지

PURPOSE: As doxorubicin cardiotoxicity is considered irreversible, early detection of cardiotoxicity and prevention of overt heart failure is essential. Although there are monitoring guidelines for cardiotoxicity, optimal timing for early detection of subclinical doxorubicin cardiotoxicity is still obscure. The purpose of this study is to determine optimal timing of cardiac monitoring and risk factors for early detection of doxorubicin cardiotoxicity in young adult patients with breast cancer. METHODS: Medical records of 1,013 breast cancer patients diagnosed from January 2009 to December 2010 is being reviewed and analyzed. Properly monitored patients are defined as patients who underwent transthoracic echocardiography before and after the chemotherapy. The definition of subclinical cardiotoxicity (SC) either decreases left ventricular ejection fraction (LVEF) more than 10% or the LVEF declines under 55% from baseline without heart failure symptoms. RESULTS: Twenty-nine out of 174 (16.7%) properly monitored young adult female patients (mean age, 52+/-10 years old) developed SC. The mean interval of cardiac evaluation of SC group was 5.5+/-3.0 months. Among the risk factors, the history of coronary artery disease, cumulative dose of doxorubicin > or =300 mg/m2 and use of trastuzumab after doxorubicin therapy were associated with development of SC. At cumulative dose of doxorubicin 244.5 mg/m2, SC can be predicted (sensitivity, 71.4%; specificity, 70.9%; area under the curve, 0.741; 95% confidence interval, 0.608-0.874; p=0.001). CONCLUSION: In young adult patients with breast cancer, SC was common at cumulative dose of doxorubicin <300 mg/m2 and early performance of cardiac monitoring before reaching the conventional critical dose of doxorubicin might be a proper strategy for early detection of SC.

Resposta da frequência cardíaca e da concentração de lactato após cada segmento do triathlon olímpico / Heart rate and blood lactate concentration response after each segment of the Olympic Triathlon event

INTRODUÇÃO: As respostas fisiológicas de cada uma das modalidades envolvidas no triathlon são diferentes. Cargas de treino poderiam ser melhores prescritas se consideradas as individualidades fisiológicas de cada segmento para cada atleta. OBJETIVO: Observar o comportamento das variáveis fisiológicas, frequência cardíaca (FC) e concentração de lactato sanguíneo, antes e depois de cada segmento do triathlon: natação, ciclismo e corrida. MÉTODOS: Doze atletas do sexo masculino cumpriram uma prova de triathlon com distância olímpica. Coletas de sangue da polpa digital foram feitas antes do início da prova, após a natação, após o ciclismo, após a corrida e, ainda, uma hora após a prova. Cada atleta foi monitorizado com frequencímetro (Polar® S610) durante toda a prova. Análises estatísticas foram realizadas através da correlação de Spearman e teste de Wilcoxon para amostras não paramétricas (p<0,05). RESULTADOS: Nesta pesquisa, a maior intensidade foi registrada, em ambos os parâmetros fisiológicos, durante o ciclismo (86,3% da frequencia cardíaca máxima (FCmáx); 6,98mmol), seguida pela natação (85,2% FCmáx; 5,75mmol) e corrida (83,6% FCmáx; 4,47mmol), respectivamente. CONCLUSÃO: Conclui-se que a prescrição da carga de treino para o triathlon será mais eficiente se baseada nas respostas fisiológicas (FC e o lactato sanguíneo) individuais de cada modalidade.

INTRODUCTION: The physiological responses of each part of Triathlon are different; better training loads could be prescribed for athletes considering each segment of this sport. OBJECTIVE: The purpose of this study was to investigate the behavior of physiological variables - heart rate and blood lactate concentration - before the event, after each segment of an Olympic Triathlon: swimming, cycling and running, and after recovery time. METHODS: The sample included twelve male triathletes who participated in a triathlon event with Olympic distance. Capillary blood samples were taken from the fingertip in the beginning of the event (pre-event), after each segment (swimming, cycling, running) and after 1 hour of recovery. Each athlete was monitored during the entire event by a heart rate monitor (Polar® S610). Statistical procedures included: Spearman correlations and Wilcoxon non parametric tests (p<0.05). RESULTS: The study results showed that the highest intensity was reached during cycling (HRmax: 86.3%; Lac: 6.98 mmol/L) in both physiological parameters, followed by swimming (HRmax: 85.2%, Lac: 5.75 mmol/L) and running (HRmax: 83.6%, lac: 4.47mmol), respectively. CONCLUSIONS: Training load prescription based on different physiological markers responses - such as heart rate and blood lactate concentration - of each triathlon segment will be more efficient for the Olympic triathlon demands.