Crisis adrenal neonatal secundaria a hipoplasia hipofisaria / Neonatal Adrenal Crisis Secondary to Pituitary Hypoplasia

Introducción: La insuficiencia adrenal hipotálamo hipofisaria usualmente se manifiesta secundaria a tumores y, cuando resulta congénita se asocia, con frecuencia, con otras deficiencias hormonales. La crisis adrenal suele presentarse en su debut y puede resultar potencialmente mortal. Objetivo: Examinar el caso de una paciente con insuficiencia adrenal central que debutó con una crisis adrenal congénita. Presentación del caso: Recién nacida a término, padres no consanguíneos, hospitalizada a los 9 días de vida por clínica de una semana con múltiples episodios eméticos y apnea. Ingresó con deshidratación severa, hipotensa y estuporosa. Además, se encontró acidosis metabólica severa, hipoglucemia persistente, hiponatremia e insuficiencia prerrenal. Ante la no mejoría de su estado hemodinámico, a pesar del uso de cristaloides y vasopresores, finalmente mejoró con la administración de dosis altas de hidrocortisona. El diagnóstico de deficiencia de cortisol de origen central se realizó con un test dinámico de insulina y la resonancia magnética nuclear hipofisaria. Conclusiones: La crisis adrenal se debe tener presente como diagnóstico diferencial en episodios agudos con inestabilidad hemodinámica persistente e hipoglucemia de difícil manejo. Adicionalmente, hay que considerar que existen otras causas menos comunes de insuficiencia adrenal en neonatos como la hipoplasia hipofisaria(AU)

Introduction: Hypothalamic-pituitary adrenal insufficiency usually manifests secondary to tumors and, when congenital, is often associated with other hormonal deficiencies. Adrenal crisis usually occurs at its onset and can be life threatening. Objective: To review the case of a patient with central adrenal insufficiency who had an onset with a congenital adrenal crisis. Case presentation: Term newborn, non-consanguineous parents, hospitalized at 9 days of life for a week-long clinical presentation with multiple emetic episodes and apnea. She was admitted with severe dehydration, hypotensive and stuporous. In addition, severe metabolic acidosis, persistent hypoglycemia, hyponatremia and prerenal failure were found. Given the lack of improvement of her hemodynamic status, despite the use of crystalloids and vasopressors, she finally improved with the administration of high doses of hydrocortisone. The diagnosis of cortisol deficiency of central origin was made with a dynamic insulin test and pituitary nuclear magnetic resonance imaging. Conclusions: Adrenal crisis should be kept in mind as a differential diagnosis in acute episodes with persistent hemodynamic instability and difficult-to-manage hypoglycemia. Additionally, other less common causes of adrenal insufficiency in neonates, such as pituitary hypoplasia, should be considered(AU)

Viabilidade miocárdica na prática clínica / Assessing myocardial viability in clinical practice

Embora a avaliação da viabilidade miocárdica seja comum na prática do cardiologista, muitos médicos têm dúvidas a respeito dos resultados dos métodos diagnósticos. A medicina nuclear tem papel importante nos estudos de viabilidade, mas os laudos precisam ser interpretados num contexto clínico e fisiopatológico. Este artigo teve o objetivo de revisar a origem e a evolução do conceito da viabilidade miocárdica. São expostos os métodos diagnósticos com ênfase na medicina nuclear com uma explicação funcional sobre cada tipo de exame. A partir disso, são mostradas imagens como exemplos e é proposta uma maneira de atuar nesses casos baseada na clínica, na porcentagem de miocárdio acometido e na topografia das lesões coronarianas (proximais ou distais). (AU)

Although assessing myocardial viability is a common cardiology practice, many physicians question the results of diagnostic methods. Nuclear medicine plays an important role in viability studies, but the reports require interpretation in a clinical and pathophysiological context. this article was aimed at reviewing the origin and evolution of myocardial viability. Here we present diagnostic methods by emphasizing nuclear medicine and provide a functional explanation of each test type using example images. We also propose how to act in these cases based on clinic examination findings, the percentage of affected myocardium, and coronary lesion topography (proximal or distal).(AU)

Trends of vasopressor use in intensive care units in Colombia / Tendencias de consumo de vasopresores en unidades de cuidados intensivos de Colombia

Abstract Introduction Vasopressors are essential in the management of various types of shock. Objective To establish the trend of vasopressors use in the intensive care units (ICU) in a population of patients affiliated with the Colombian Health System, 2010-2017. Methods Observational trial using a population database of patients hospitalized in eleven ICUs in various cities in Colombia. The drugs dispensed to hospitalized patients over 18 years old, from January 2010 until December 2017 were considered. A review and analysis of the vasopressors dispensed per month was conducted, taking into account sociodemographic and pharmacological variables (vasopressor used and daily doses defined per 100/beds/day (DBD). Results 81,348 dispensations of vasopressors, equivalent to 26,414 treatments in 19,186 patients receiving care in 11 hospitals from 7 cities were reviewed. The mean age of patients was 66.3±18.1 years and 52.6 % were males. Of the total number of treatments recorded, 17,658 (66.8 %) were with just one vasopressor. Norepinephrine was the most frequently prescribed drug (75.9 % of the prescriptions dispensed; 60.5 DBD), followed by adrenaline (26.6 %; 41.6 DBD), dopamine (19.4%), dobutamine (16.0 %), vasopressin (8.5 %) and phenylephrine (0.9 %). The use of norepinephrine increased from 2010 to 2017 (+6.19 DBD), whilst the use of other drugs decreased, particularly the use of adrenaline (-60.6 DBD) and dopamine (-10.8 DBD). Conclusions Norepinephrine is the most widely used vasopressor showing a growing trend in terms of its use during the study period, which is supported by evidence in favor of its effectiveness and safety in patients with shock.

Resumen Introducción Los fármacos vasopresores son fundamentales en el manejo de los diferentes tipos de choque. Objetivo Determinar la tendencia de utilización de fármacos vasopresores en unidades de cuidados intensivos (UCI) en una población de pacientes afiliados al Sistema de Salud de Colombia, 2010-2017. Métodos Estudio observacional, a partir de una base de datos poblacional con pacientes hospitalizados en once UCI de diferentes ciudades de Colombia. Se obtuvieron las dispensaciones de pacientes mayores de 18 años hospitalizados desde enero de 2010 hasta diciembre de 2017. Se hizo revisión y análisis de la dispensación mensual de vasopresores. Se consideraron variables sociodemográficas y farmacológicas (medicamento vasopresor usado y dosis diarias definidas por 100 camas/día [DCD]). Resultados Se revisaron 81.348 dispensaciones de vasopresores, equivalentes a 26.414 terapias en 19.186 pacientes atendidos en 11 hospitales de 7 ciudades, cuya edad promedio fue 66,3±18,1 años y el 52,6 % eran hombres. Del total de terapias registradas, 17.658 (66,8 %) fueron con un solo vasopresor. La norepinefrina fue el más comúnmente prescrito (75,9 % de las dispensaciones; 60,5 DCD), seguido por adrenalina (26,6 %; 41,6 DCD), dopamina (19,4 %), dobutamina (16,0 %), vasopresina (8,5 %) y fenilefrina (0,9 %). El uso de norepinefrina se incrementó de 2010 a 2017 (+6,19 DCD), mientras que el de otros fármacos disminuyó, especialmente adrenalina (-60,6 DCD) y dopamina (-10,8 DCD). Conclusiones La norepinefrina es el fármaco vasopresor más utilizado y el que ha demostrado una tendencia de uso incremental durante el periodo de estudio, lo cual está respaldado por evidencia a favor de su efectividad y seguridad en pacientes con choque.

Análise da Segurança e Exequibilidade do Ecocardiograma sob Estresse com Dobutamina em Dez Mil e Seis Exames de uma População Geral / Analysis of the Safety and Feasibility of Dobutamine Stress Echocardiography in Ten Thousand and Six Tests of a General Population

Fundamento: Durante o ecocardiograma sob estresse com dobutamina, podem ocorrer efeitos adversos e exames inconclusivos. Objetivo: Avaliar em uma grande população geral a segurança e a exequibilidade do ecocardiograma sob estresse com dobutamina. Métodos: Estudo de 10.006 ecocardiogramas sob estresse com dobutamina realizados no período de julho de 1996 a setembro de 2007. A dobutamina foi administrada em quatro estágios (10, 20, 30 e 40 µcg.kg-1.min-1) para pesquisa de isquemia miocárdica e iniciada com 5 µcg.kg- ¹.min-1 apenas na análise de viabilidade miocárdica. A atropina foi iniciada conforme os protocolos vigentes. Foram verificados dados clínicos, hemodinâmicos e efeitos adversos associados ao ecocardiograma sob estresse com dobutamina. Resultados: Durante os ecocardiogramas sob estresse com dobutamina, ocorreu angina típica (8,9%), pico hipertensivo (1,7%), ectopias ventriculares isoladas (31%), taquiarritmia supraventricular (1,89%), fibrilação atrial (0,76%) e taquicardia ventricular não sustentada (0,6%). Os efeitos adversos citados foram mais frequentes nos pacientes com ecocardiogramas sob estresse com dobutamina positivos para isquemia. A desaceleração sinusal paradoxal (0,16%) não ocorreu em ecocardiogramas sob estresse com dobutamina positivo. As três complicações graves ocorreram em ecocardiogramas sob estresse com dobutamina positivos para isquemia. Foram dois casos (0,02%) com fibrilação ventricular e um caso de síndrome coronariana aguda (0,01%). Não houve caso de taquicardia ventricular sustentada, ruptura cardíaca, assistolia ou óbito. Comparados aos exames concluídos, nos inconclusivos, os pacientes usaram menos atropina (81,5% versus 49,9%; p< 0,001) e mais betabloqueador (4,7% versus 19%; p< 0,001), apresentando mais pico hipertensivo (1,1% versus 14,2%; p = 0,0001) e taquicardia ventricular não sustentada (0,5% versus 2,2%; p< 0,001). Conclusão: O ecocardiograma sob estresse com dobutamina realizado de forma apropriada é seguro e apresenta elevada exequibilidade.

Background: Adverse effects and inconclusive results may occur on dobutamine stress echocardiography. Objective: To assess the safety and feasibility of dobutamine stress echocardiography in a large general population. Methods: A total of 10,006 dobutamine stress echocardiographies were performed between July 1996 and September 2007. Dobutamine was administered in four stages (10, 20, 30, and 40 µcg·kg-1·min-1) to research myocardial ischemia starting with 5 µcg·kg- ¹·min-1 to analyze myocardial viability. Atropine administration was initiated according to current protocols. Clinical, hemodynamic, and adverse effect data associated with dobutamine stress echocardiography findings were verified. Results: Typical angina (8.9%), hypertensive peak (1.7%), isolated ventricular ectopias (31%), supraventricular tachyarrhythmia (1.89%), atrial

Effects of Beta; 1-adrenoceptors in the Basolateral Amygdala on Spatial Memory, Passive Avoidance, Long-term Potentiation and Neuronal Arborization in the Hippocampal CA1 Region in Response to Unavoidable Stress

Abstract Norepinephrine in the basolateral amygdala (BLA) plays a pivotal role in mediating the effects of stress on memory functions in the hippocampus, however, the functional contribution of β1-adrenergic receptors on the BLA inputs to the CA1 region of hippocampus and memory function are not well understood. In the present study the role of β1-adrenoreceptor in the BLA on memory, neuronal arborization and long-term potentiation (LTP) in the CA1 region of hippocampus was examined by infusion the β1-adrenoreceptor agonist (Dobutamine; 0.5µl/side) or antagonist (Atenolol; 0.25µL/side) bilaterally into the BLA before foot-shock stress. Passive avoidance test results showed that Step-through latency time was significantly decreased in the stress group rats one, four and seven days after the stress, which intra-BLA injection of Atenolol or Dobutamine before stress couldn't attenuate this reduction. Barnes-maze results revealed that infusion of Dobutamine and Atenolol significantly reduced spatial memory indicators such as increased latency time, the number of errors and the distance traveling to achieve the target hole in the stress group. These learning impairments in stress rats correlated with a reduction of LTP in hippocampal CA1 synapses in-vivo, which infusion of Dobutamine and Atenolol couldn't attenuate the population spike amplitude and mean-field excitatory postsynaptic potentials (fEPSP) slope reduction induced by stress. Also, the Golgi-Cox staining demonstrated that infusion of Atenolol attenuated stress decreased CA1 region dendritic and axonal arborization. These results suggest that β1-adrenergic receptors activation or block seem to exacerbate stress-induced hippocampal memory deficits and this effect is independent of CA1 LTP modulation.

Continuous Intravenous Inotropes in Ward Units: Expanding Therapy Outside Intensive Care using a Safety-Oriented Protocol / Inotrópicos Intravenosos Contínuos em Unidades de Enfermaria: Expandindo o Tratamento Além da Unidade de Terapia Intensiva Utilizando um Protocolo Orientado em Segurança

Abstract Selected clinically stable patients with heart failure (HF) who require prolonged intravenous inotropic therapy may benefit from its continuity out of the intensive care unit (ICU). We aimed to report on the initial experience and safety of a structured protocol for inotropic therapy in non-intensive care units in 28 consecutive patients hospitalized with HF that were discharged from ICU. The utilization of low to moderate inotropic doses oriented by a safety-focused process of care may reconfigure their role as a transition therapy while awaiting definitive advanced therapies and enable early ICU discharge.

Resumo Pacientes selecionados com insuficiência cardíaca (IC), clinicamente estáveis que necessitam de terapia inotrópica intravenosa prolongada podem se beneficiar de sua continuidade fora da unidade de terapia intensiva (UTI). Nosso objetivo foi relatar a experiência inicial e a segurança de um protocolo estruturado para terapia inotrópica em unidades de terapia não-intensiva em 28 pacientes consecutivos hospitalizados com IC que receberam alta da UTI. A utilização de doses inotrópicas baixas a moderadas, orientadas por um processo de cuidado focado na segurança, pode reconfigurar seu papel como terapia de transição enquanto aguarda terapias avançadas definitivas e permite a alta precoce da UTI.

Ligadura dos ramos da artéria torácica interna anastomosada na coronária descendente anterior e efeito nas velocidades do fluxo e no estado funcional do enxerto / Ligation of the branches of the anastomosed internal thoracic artery in the anterior descending coronary artery and the effect on flow velocities and functional status of the graft

Fundamento: Ocorre modificação no fluxo da artéria torácica interna, após sua anastomose na artéria coronária descendente anterior. Objetivo: Avaliar o efeito da ligadura dos ramos proximais da artéria torácica interna anastomosada na artéria coronária descendente anterior, quanto às velocidades e à reserva de velocidade de fluxo coronariano, em pacientes com fração de ejeção do ventrículo esquerdo preservada (> 50%). Métodos: Estudo prospectivo de pacientes com fração de ejeção do ventrículo esquerdo > 50% revascularizados. O Grupo I foi formado por 25 pacientes com ligadura dos grandes ramos da artéria torácica interna antes de sua anastomose na artéria coronária descendente anterior, e o Grupo II por 28 pacientes sem ligadura. Registrou-se o Doppler em nível proximal da artéria torácica interna no pré-operatório, pós-operatório precoce e no pós-operatório tardio de 6 meses. Foram mensurados os picos de velocidade sistólica e diastólica, e as velocidades médias sistólica e diastólica. A reserva de velocidade de fluxo coronariano foi obtida durante o ecocardiograma sob estresse com dobutamina no pós-operatório tardio de 6 meses. Resultados: No pós-operatório precoce, o pico de velocidade sistólica e a velocidade média sistólica diminuíram, enquanto aumentaram o pico de velocidade diastólica e a velocidade média diastólica nos dois grupos (p < 0,05). Do pós-operatório precoce para o tardio em 6 meses, apenas o pico de velocidade diastólica se modificou, diminuindo nos dois grupos (p < 0,05). Durante o ecocardiograma sob estresse com dobutamina, o pico de velocidade diastólica e a velocidade média diastólica aumentaram (p < 0,05), e os grupos não diferiram, mas o pico de velocidade sistólica e a velocidade média sistólica aumentaram apenas no Grupo II (p < 0,05). A reserva de velocidade de fluxo coronariano dos grupos calculada pelo pico de velocidade diastólica (Grupo I = 2,17 ± 0,64 e Grupo II = 2,28 ± 0,63) e pela velocidade média diastólica (Grupo I = 2,27 ± 0,54 e Grupo II = 2,5 ± 0,79) não diferiu. Conclusão: Em pacientes com fração de ejeção do ventrículo esquerdo preservada, a ligadura dos grandes ramos da artéria torácica interna anastomosada na artéria coronária descendente anterior não compromete a reserva de velocidade de fluxo coronariano, mas determina limitação no aumento das velocidades sistólicas

Introduction: Modification of internal thoracic artery flow occurs after its anastomosis in the left anterior descending coronary artery. Objective: To evaluate the effect of ligation of the proximal branches of anastomosed internal thoracic artery flow on the left anterior descending in relation to velocities and coronary flow velocity reserve in patients with left ventricular ejection fraction preserved (> 50%). Methods: Prospective study of patients with left ventricular ejection fraction > 50% and revascularized. Group I was composed of 25 patients with ligation of the major branches of the internal thoracic artery flow before its anastomosis in the left anterior descending coronary artery, and Group II was composed of 28 patients without ligation. Doppler was recorded at the proximal level of internal thoracic artery flow in the preoperative, early postoperative and 6 months later. The systolic peak velocity and diastolic, and systolic mean velocity and diastolic were measured. Coronary flow velocity reserve was obtained during dobutamine stress echocardiography in postoperative period 6 months later. Results: In the postoperative, the systolic peak velocity and the systolic mean velocity decreased while increasing the diastolic peak velocity and the diastolic mean velocity in the groups (p < 0.05). From the postoperative to the postoperative period 6 months later, only the diastolic peak velocity modified, occurring its decrease in the groups (p < 0.05). During the dobutamine stress echocardiography, diastolic peak velocity and the diastolic mean velocity increased (p < 0.05) and groups did not differ, however, the systolic peak velocity and the systolic mean velocity increased only in Group II (p < 0.05). The coronary flow velocity reserve of the groups calculated by diastolic peak velocity (Group I = 2.17 ± 0.64 and Group II =2.28 ± 0.63) and diastolic mean velocity (Group I = 2.27 ± 0.54 and Group II = 2.5 ± 0.79) did not differ. Conclusion: In patients with preserved left ventricular ejection fraction, the ligation of the large branches of the anastomosed internal thoracic artery flow into the left anterior descending coronary artery does not compromise the coronary flow velocity reserve, but determines limitation in the increase of the systolic velocities

Insuficiência cardíaca aguda (ICA) - decisão terapêutica: inotrópicos ou vasodilatadores? / Therapeutic decision in acute heart failure: inotropic agents or vasodilator drugs?

A insuficiência cardíaca aguda é a principal causa de hospitalização em pacientes acima de 65 anos, além de possuir altos índices de mortalidade hospitalar. Na sua abordagem terapêutica é mandatório um diagnóstico rápido e pronta caracterização do perfil hemodinâmico, baseando-se nos sinais clínicos de congestão e baixo débito cardíaco, para que possamos instituir a terapêutica com drogas endovenosas para alívio rápido dos sintomas, restabelecer a perfusão adequada dos órgãos e reduzir o risco de morte. As drogas a serem administradas de forma isolada ou em combinação são representadas pela furosemida endovenosa em infusão intermitente e contínua, dependendo do grau de congestão pulmonar e/ou sistêmica, as drogas vasodilatadoras e os agentes inotrópicos. As drogas vasodilatadoras, como o nitroprussiato de sódio e a nitroglicerina via endovenosa são, frequentemente, adicionadas aos diuréticos para o tratamento da insuficiência cardíaca aguda com perfil hemodinâmico B, promovendo estabilidade hemodinâmica mais rápida e pronto alívio da dispneia. O nitroprussiato de sódio é preferível nos pacientes com IC perfil B com níveis elevados de resistência vascular periférica e grave congestão pulmonar. Já a nitroglicerina é preferível nos pacientes com cardiopatia isquêmica ou com insuficiência coronariana aguda associada à insuficiência cardíaca. Os agentes inotrópicos positivos estão indicados nos pacientes com IC aguda e evidências de baixo débito cardíaco (perfil hemodinâmico C), a fim de garantir a melhora da perfusão tissular mediante aumento do débito cardíaco, principalmente, nos pacientes hipotensos e com piora da função renal. A associação de inotrópicos com vasodilatadores deve ser considerada quando existe a combinação de baixo débito cardíaco e aumento significativo de resistência vascular pulmonar e ou sistêmica

Acute heart failure is the leading cause of hospitalization in patients over 65 years of age and is accompanied by high hospital mortality rates. In its therapeutic approach, rapid diagnosis and prompt characterization of the hemodynamic profile based on clinical signs of congestion and low cardiac output are mandatory so that we can provide intravenous drug therapy for rapid symptom relief to restore adequate organ perfusion and reduce the risk of death. Drugs to be used alone or in combination are represented by intravenous furosemide in intermittent infusion and continue to depend on the degree of pulmonary and/or systemic congestion, vasodilator drugs, and inotropic agents. Vasodilator drugs, such as sodium nitroprusside and intravenous nitroglycerin, are often added to diuretics for the treatment of acute cardiac insufficiency with hemodynamic profile B, promoting faster hemodynamic stability and prompt relief of dyspnea. Sodium nitroprusside is preferable in patients with hemodynamic profile B with high peripheral vascular resistance and severe pulmonary congestion. Nitroglycerin is preferable in patients with ischemic heart disease or acute coronary insufficiency associated with heart failure (HF). Positive inotropic agents are indicated in patients with acute HF and evidence of low cardiac output (hemodynamic profile C) to ensure improvement in tissue perfusion by increasing cardiac output, especially in patients with hypotension and worsening renal function. The association of inotropes and vasodilators should be considered when there is a combination of low cardiac output and significant increase in pulmonary and/or systemic vascular resistance

Análise da segurança e dos preditores de arritmias durante o ecocardiograma sob estresse com Dobutamina em um ambiente não hospitalar / Analyzing the safety and predictors of arrhythmias during dobutamine-atropine estress echocardiography in a non-hospital setting

Fundamento: O ecocardiograma sob estresse com dobutamina-atropina (EEDA) é um exame acessível e importante, principalmente em pacientes sob investigação de doença coronariana. Contudo, faz-se necessário a avaliação de sua segurança, devido ao seu emprego em pacientes com patologias cada vez mais complexas, graves e idosos.Objetivo: Confirmar segurança do EEDA e avaliar os preditores de arritmias em ambiente não hospitalar.Métodos: EEDA foi realizado com o objetivo de avaliar isquemia utilizando o protocolo padrão de infusão de dobutamina de 5 a 40 mcg/kg/min associado a atropina.Resultados: Foram avaliados de forma prospectiva 2227 pacientes no período de setembro a novembro de 2010. Idade média foi de 60,7 +/- 12,5 anos e 60,8% eram mulheres. A fração de ejeção média foi de 67,9% +/- 9. Dentre dos eventos adversos, 12 pacientes apresentaram resposta hipertensiva, 466 arritmias, 58 cefaleias e 57 dores precordial. Nenhum paciente apresentou infarto agudo do miocárdio, fibrilação ventricular, ruptura cardíaca, assistolia ou morte. Quanto ao surgimento das arritmias significativas, 3 pacientes apresentaram fibrilação atrial,16 taquicardias supraventricular sustentada, 19 taquicardias ventricular não sustentada e 2 taquicardias ventricular sustentada. Nestes pacientes, idade (OR = 1,0559, p = 0,0002) e o índice de escore de contração segmentar (IECS) em repouso > 1 (OR 2,5039, p = 0,0354) foram preditores independentes para o surgimento de arritmias significativas durante o exame.Conclusão: O EEDA mostrou-se seguro nesse grupo de pacientes em ambiente não hospitalar. Idade e IECS em repouso > 1 foram preditores independentes para o surgimento de arritmias significativas durante o exame

Background: Dobutamine-atropine stress echocardiography (DASE) is an accessible and important test, especially in patients under investigation for coronary artery disease. However, it is necessary to evaluate its safety, as it is used in patients with increasingly complex and serious conditions and in seniors.Objective: To confirm the safety of DASE and evaluate the predictors of arrhythmias in a non-hospital setting. Methods: DASE was performed to evaluate ischemia using the standard protocol of dobutamine infusion of 5 to 40 mcg/kg/min associated with atropine. Results: From September to November 2010, 227 patients were evaluated prospectively. The mean age was 60.7 +/- 12.5 years old and 60.8% were females. Mean ejection fraction was 67.9 +/- 9. Among the adverse events, 12 patients presented hypertensive response, 466 had arrhythmia, 58 had headaches and 57 had precordial pain. No patient had acute myocardial infarction, ventricular fibrillation, cardiac rupture, asystole or death. As for the onset of significant arrhythmia, three patients had atrial fibrillation, 16 had sustained supraventricular tachycardia, 19 had non-sustained ventricular tachycardia and 2 had sustained ventricular tachycardia. In these patients, age (OR = 1.0559, p = 0.0002) and segmental contractility index at rest (SCIr) > 1 (OR 2.5039, p = 0.0354) were independent predictors for the onset significant arrhythmia during the test. Conclusion: DASE was proven safe in this group of patients in a non-hospital setting. Age and SCIr > 1 were independent predictors for the onset of significant arrhythmia during the test

Prevalencia de cardiopatía isquémica asintomática en pacientes con diabetes mellitus tipo 2 / Prevalence of asymptomatic ischaemic heart disease in patients with type 2 diabetes mellitus

Resumen Introducción: La enfermedad cardiovascular es la causa principal de muerte en pacientes con diabetes mellitus. La prevalencia de cardiopatía isquémica asintomática es más alta en pacientes diabéticos que en no diabéticos y se asocia a peor pronóstico. Objetivo: Identificar la prevalencia de cardiopatía isquémica asintomática en pacientes con diabetes mellitus tipo 2 en un hospital de tercer nivel de atención de Guatemala y analizar la posible asociación de dicha enfermedad con características epidemiológicas, clínicas y metabólicas. Métodos: Estudio de corte transversal en el que se estudió una muestra de 92 pacientes diabéticos seleccionados de forma aleatoria simple. Se realizó electrocardiograma, que cuando fue negativo para isquemia ameritó prueba de esfuerzo, o de lo contrario, ecocardiograma de estrés con dobutamina. Resultados: La edad media de los participantes fue de 57 años, 88% de los cuales eran mujeres; la duración media de la diabetes fue 7 años. Se encontró cardiopatía isquémica asintomática en el 22,8% de los casos. No se hallaron posibles asociaciones entre cardiopatía isquémica asintomática y edad, sexo, enfermedad arterial periférica, índice de masa corporal, índice tobillo-brazo, hipertensión arterial, dislipidemia, tabaquismo activo, sedentarismo, sobrepeso/obesidad, alcoholismo, glucosa en ayunas, hemoglobina glicosilada, colesterol total, colesterol HDL, colesterol LDL, ácido úrico, creatinina, tasa de filtrado glomerular y microalbuminuria. Conclusiones: La prevalencia de cardiopatía isquémica asintomática en la población estudiada con diabetes mellitus tipo 2 fue de 22,8%. No se encontraron posibles asociaciones de cardiopatía isquémica asintomática con las variables estudiadas.

Abstract Introduction: Cardiovascular disease is the main cause of death in patients with diabetes mellitus. The prevalence of asymptomatic ischaemic heart disease is higher in diabetic patients than in non-diabetic ones, and is associated with a worse prognosis. Objective: To determine the prevalence of asymptomatic ischaemic heart disease in patients with type 2 diabetes mellitus in a third level of care hospital in Guatemala, as well as to analyse the possible relationship of this disease with epidemiological, clinical, and metabolic characteristics. Methods: A cross-sectional study was conducted on a sample of 92 randomly selected diabetic patients. An electrocardiogram was performed, which when it was negative for ischaemia, an exercise stress test or a dobutamine stress echocardiogram was performed. Results: The mean age of the participants was 57 years, 88% of whom were women. The mean duration of the diabetes was 7 years. Asymptomatic ischaemic heart disease was found in 22.8% of case. No significant associations were found between ischaemic heart disease and age, gender, peripheral arterial disease, body mass index, ankle-brachial index, arterial hypertension, dyslipidaemia, active smoking, sedentarism, overweight/obesity, alcoholism, fasting glucose, glycosylated haemoglobin, total cholesterol, HDL-cholesterol, LDL-cholesterol, uric acid, creatinine, glomerular filtration rate, and urine microalbumin. Conclusions: The prevalence of asymptomatic ischaemic heart disease was 22.8% in the population studied with type 2 diabetes mellitus. No significant associations were found between ischaemic heart disease and the variables studied.

An Alternative Method to Calculate Simplified Projected Aortic Valve Area at Normal Flow Rate / Um Método Alternativo para o Cálculo da Área Valvular Aórtica Projetada Simplificada em Uma Taxa de Fluxo Normal

Abstract Background: Simplified projected aortic valve area (EOAproj) is a valuable echocardiographic parameter in the evaluation of low flow low gradient aortic stenosis (LFLG AS). Its widespread use in clinical practice is hampered by the laborious process of flow rate (Q) calculation. Objetive: This study proposes a less burdensome, alternative method of Q calculation to be incorporated in the original formula of EOAproj and measures the agreement between the new proposed method of EOAproj calculation and the original one. Methods: Retrospective observational single-institution study that included all consecutive patients with classic LFLG AS that showed a Q variation with dobutamine infusion ≥ -15-% by both calculation methods. Results: Twenty-two consecutive patients with classical LFLG AS who underwent dobutamine stress echocardiography were included. Nine patients showed a Q variation with dobutamine infusion calculated by both classical and alternative methods ≥ -15-% and were selected for further statistical analysis. Using the Bland-Altman method to assess agreement we found a systematic bias of 0,037 cm2 (95% CI 0,004 - 0,066), meaning that on average the new method overestimates the EOAproj in 0,037 cm2 compared to the original method. The 95% limits of agreement are narrow (from -0,04 cm2 to 0,12 cm2), meaning that for 95% of individuals, EOAproj calculated by the new method would be between 0,04 cm2 less to 0,12 cm2 more than the EOAproj calculated by the original equation. Conclusion: The bias and 95% limits of agreement of the new method are narrow and not clinically relevant, supporting the potential interchangeability of the two methods of EOAproj calculation. As the new method requires less additional measurements, it would be easier to implement in clinical practice, promoting an increase in the use of EOAproj.

Resumo Fundamento: A área valvular aórtica projetada simplificada (AEOproj) é um parâmetro ecocardiográfico valioso na avaliação da estenose aórtica de baixo fluxo e baixo gradiente (EA BFBG). Sua utilização na prática clínica é limitada pelo trabalhoso processo de cálculo da taxa de fluxo (Q). Objetivos: Este estudo propõe um método alternativo, menos complexo, para o cálculo da Q para ser incorporado na fórmula original da AEOproj, e mede a concordância entre o novo método proposto para o cálculo da AEOproj em comparação ao método original. Métodos: Estudo retrospectivo, observacional, unicêntrico que incluiu todos os pacientes com AE BFBG clássica com variação da Q com infusão de dobutamina ≥ -15-% por ambos os métodos. Resultados: Foram incluídos 22 pacientes consecutivos com AE BFBG clássico, que se submeteram à ecocardiografia sob estresse com dobutamina. Nove pacientes apresentaram uma variação da Q com infusão de dobutamina calculada tanto pelo método clássico como pelo método alternativo ≥ -15-%, e foram selecionados para análise estatística. Utilizando método Bland-Altman para avaliar a concordância, encontramos um viés sistemático de 0,037 cm2 (IC 95% 0,004 - 0,066), o que significa que, em média, o novo método superestima a AEOproj em 0m037 cm2 em comparação ao método original. Os limites de concordância de 95% são estreitos (de -0,04 cm2 a 0,12 cm2), o que significa que para 95% dos indivídios, a AEOproj calculada pelo novo método estaria entre 0,04 cm2 menos a 0,12 cm2 mais que a AEOproj calculada pela equação original. Conclusão: O viés e os limites de 95% de concordância do novo método são estreitos e não são clinicamente relevantes, o que corrobora a intercambialidade dos dois métodos de cálculo da AEOproj. Uma vez que o novo método requer menos medidas, seria mais fácil de ser implementado na prática clínica, promovendo um aumento na utilização da AEOproj.

Real World Utility of Dobutamine Stress Echocardiography in Predicting Perioperative Cardiovascular Morbidity and Mortality after Orthotopic Liver Transplantation

BACKGROUND AND OBJECTIVES: Stress echocardiography is the current standard for cardiac risk stratification of patients undergoing orthotopic liver transplantation (OLT). We aim to evaluate the role of dobutamine stress echocardiography (DSE) in predicting perioperative major adverse cardiac event (MACE) in patients undergoing OLT. METHODS: This was a single-center retrospective study including 144 OLT patients. Of 144 patients, 118 had DSE. MACE included myocardial infarction (MI), heart failure (HF), cardiovascular and all-cause death 1 year after OLT. RESULTS: Our study cohort included 118 patients. The mean age was 57.3±8.2 years (range, 25–72 years). There were 85 men and 33 women, male to female ratio being 2.6:1. Of 118, 15 (13%) had positive DSE and 103 (87%) had negative DSE. Perioperative MACE incidence was 5.9% (95% confidence interval [CI], 2.6–12.3%). In predicting MACE, DSE had sensitivity of 5.6% (95% CI, 0.2–29.4%), specificity 86% (95% CI, 77.3–91.9%), positive predictive value 6.7% (95% CI, 0.3–33.4%), and negative predictive value (NPV) 83.5% (95% CI, 74.6–89.8%). Eighteen patients had MACE in first year post OLT (15%, 95% CI, 9.5–23.3%). Adverse events included cardiogenic shock (2/18), systolic HF (2/18), non-ST-elevated MI (7/18), cardiac mortality (3/18), and all-cause mortality (7/18). The overall complication rate of DSE was 17% (20/118). CONCLUSIONS: In our cohort, DSE had a low sensitivity but high NPV in predicting perioperative MACE post OLT. A similar trend was noted for DSE in predicting 1-year MACE post OLT. We reiterate the need of a better screening and risk stratification tool for OLT.

The Safety and Utility of Dobutamine Stress Echocardiography for Pre-operative Risk Stratification in Orthotopic Liver Transplantation

No abstract available.

Anesthetic Management for Elective Total Hip Replacement Arthoroplasty in a Patient with Eisenmenger's Syndrome

Eisenmenger's syndrome describes the elevation of pulmonary arterial pressure to the systemic level caused by an increased pulmonary vascular resistance with reversed or bi-directional shunt through an intracardiac or aortopulmonary communication. We report the case of 48-year-old woman with an elective total hip replacement arthroplasty for right femur neck fracture with Eisenmenger's syndrome secondary to large atrial septal defect. Anesthesia was induced with etomidate and rocuronium, maintained with desflurane 5 vol% and O₂ 3 L/min. Mirinone and norepinephrine were infused continuously to decrease right to left shunt. The patient was extubated after spontaneous breathing recovery and transferred to the intensive care unit. She was treated with mirinone, norepinephrine, dopamine, and dobutamine for hypoxemia and hypotension. After 3 hours of admission to intensive care unit, the patient had a cardiac arrest and died 30 minutes later.

Espectro dos efeitos cardiovasculares da dobutamina - de voluntários saudáveis a pacientes em choque séptico / The spectrum of cardiovascular effects of dobutamine - from healthy subjects to septic shock patients

RESUMO A dobutamina é o inotrópico mais comumente utilizado em pacientes com choque séptico, com o objetivo de aumentar o débito cardíaco e corrigir a hipoperfusão. Embora alguns ensaios clínicos tenham demonstrado que a dobutamina pode melhorar a hemodinâmica sistêmica e regional, outras pesquisas identificaram que seus efeitos são heterogêneos e imprevisíveis. Nesta revisão, analisamos as propriedades farmacodinâmicas da dobutamina e seus efeitos fisiológicos. Nosso objetivo foi demonstrar que os efeitos da dobutamina podem diferir entre voluntários saudáveis, estudos experimentais e insuficiência cardíaca clínica, em modelos de estudo em animais e em pacientes com choque séptico. Discutimos as evidências que suportam a afirmativa de que a dobutamina utilizada no tratamento do choque séptico frequentemente se comporta como fármaco cronotrópico e vasodilatador, sem evidências de ação inotrópica. Como seus efeitos colaterais são muito comuns e os benefícios terapêuticos não são claros, sugerimos que ela deve ser utilizada com cautela no choque séptico. Antes de uma decisão terapêutica definitiva, a eficácia e a tolerabilidade da dobutamina devem ser avaliadas por um tempo curto com monitoramento estrito de seus efeitos positivos e efeitos colaterais negativos.

ABSTRACT Dobutamine is the inotrope most commonly used in septic shock patients to increase cardiac output and correct hypoperfusion. Although some experimental and clinical studies have shown that dobutamine can improve systemic and regional hemodynamics, other research has found that its effects are heterogenous and unpredictable. In this review, we analyze the pharmacodynamic properties of dobutamine and its physiologic effects. Our goal is to show that the effects of dobutamine might differ between healthy subjects, in experimental and clinical cardiac failure, in animal models and in patients with septic shock. We discuss evidence supporting the claim that dobutamine, in septic shock, frequently behaves as a chronotropic and vasodilatory drug, without evidence of inotropic action. Since the side effects are very common, and the therapeutic benefits are unclear, we suggest that dobutamine should be used cautiously in septic shock. Before a definitive therapeutic decision, the efficacy and tolerance of dobutamine should be assessed during a brief time with close monitoring of its positive and negative side effects.

Noradrenaline and dobutamine effects on the volume expansion with normal saline in rabbits subjected to hemorrhage

ABSTRACT PURPOSE: To evaluate the effects of dobutamine (DB), noradrenaline (NA), and their combination (NADB), on volume retention in rabbits submitted to hemorrhage. METHODS: Thirty six rabbits were randomly divided into 6 groups: SHAM, Control, Saline, DB, NA, DB+NA. All the animals, except for SHAM, were subjected to hemorrhage of 25% of the calculated blood volume. Control animals were replaced with their own blood. The other groups received NSS 3 times the volume withdrawn. The intravascular retention, hematocrit, diuresis, central venous pressure, mean arterial pressure, NGAL, dry-to-wet lung weight ratio (DTWR) and the lung and kidney histology were analyzed. RESULTS: Replacement with NSS and NA, DB or NA+DB did not produce differences in the intravascular retention. After hemorrhage, the animals presented a significant decrease in the MAP and CVP, which were maintained until volume replacement. Regarding NGAL, dry-to-wet-lung-weight ratio, lung and kidney histology, there were no statistical differences between the groups. CONCLUSION: The use of noradrenaline, dobutamine or their combination did not increase the intravascular retention of volume after normal saline infusion.