¿Fue útil una estrategia VIP para el coronavirus? / Was a Vectored-Immunoprophylaxis Strategy Useful against Coronavirus?

Estimado editor: Los albores del año 2020 le depararon a la humanidad una terrible sorpresa: se reportaban los primeros casos de la posteriormente famosa COVID-19, una enfermedad, cuyo estrepitoso avance la convirtió en una pandemia declarada el 11 de marzo de 2020.1 Desde entonces, muchas han sido las estrategias destinadas a paliar sus efectos deletéreos. Ciertamente, fueron apareciendo esperanzadoras medidas sanitarias, unas con mayor éxito o acogida que otras, pero sin el suficiente respaldo científico como para avalar su uso y convertirse en la estrategia ideal. De ellas, algunas ya validadas para el tratamiento de pacientes críticos, como lo son la ventilación-oxigenoterapia (V), la infusión de líquidos-fluidoterapia (I) y la pronación (P), también fueron parte del intento. A ellas serán dedicadas estas líneas de reflexión...(AU)

Establishment and application of the ten-fold rehydration formula for emergency resuscitation of pediatric patients after extensive burns / 中华烧伤杂志

Objective: To investigate the scientificity and feasibility of the ten-fold rehydration formula for emergency resuscitation of pediatric patients after extensive burns. Methods: A retrospective observational study was conducted. The total burn area of 30%-100% total body surface area (TBSA) and body weight of 6-50 kg in 433 pediatric patients (250 males and 183 females, aged 3 months to 14 years) with extensive burns who met the inclusion criteria and admitted to the burn departments of 72 Class A tertiary hospitals were collected. The 6 319 pairs of simulated data were constructed after pairing each body weight of 6-50 kg (programmed in steps of 0.5 kg) and each total burn area of 30%-100% TBSA (programmed in steps of 1%TBSA). They were put into three accepted pediatric rehydration formulae, namely the commonly used domestic pediatric rehydration formula for burn patients (hereinafter referred to as the domestic rehydration formula), the Galveston formula, and the Cincinnati formula, and the two rehydration formulae for pediatric emergency, namely the simplified resuscitation formula for emergency care of patients with extensive burns proposed by the World Health Organization's Technical Working Group on Burns (TWGB, hereinafter referred to as the TWGB formula) and the pediatric ten-fold rehydration formula proposed by the author of this article--rehydration rate (mL/h)=body weight (kg) × 10 (mL·kg-1·h-1) to calculate the rehydration rate within 8 h post injury (hereinafter referred to as the rehydration rate). The range of the results of the 3 accepted pediatric rehydration formulae ±20% were regarded as the reasonable rehydration rate, and the accuracy rates of rehydration rate calculated using the two pediatric emergency rehydration formulae were compared. Using the maximum burn areas (55% and 85% TBSA) corresponding to the reasonable rehydration rate calculated by the pediatric ten-fold rehydration formula at the body weight of 6 and 50 kg respectively, the total burn area of 30% to 100% TBSA was divided into 3 segments and the accuracy rates of the rehydration rate calculated using the 2 pediatric emergency rehydration formulae in each segment were compared. When neither of the rehydration rates calculated by the 2 pediatric emergency rehydration formulae was reasonable, the differences between the two rehydration rates were compared. The distribution of 433 pediatric patients in the 3 previous total burn area segments was counted and the accuracy rates of the rehydration rate calculated using the 2 pediatric emergency rehydration formulae were calculated and compared. Data were statistically analyzed with McNemar test. Results: Substitution of 6 319 pairs of simulated data showed that the accuracy rates of the rehydration rates calculated by the pediatric ten-fold rehydration formula was 73.92% (4 671/6 319), which was significantly higher than 4.02% (254/6 319) of the TWGB formula (χ2=6 490.88,P<0.05). When the total burn area was 30%-55% and 56%-85% TBSA, the accuracy rates of the rehydration rates calculated by the pediatric ten-fold rehydration formula were 100% (2 314/2 314) and 88.28% (2 357/2 670), respectively, which were significantly higher than 10.98% (254/2 314) and 0 (0/2 670) of the TWGB formula (with χ2 values of 3 712.49 and 4 227.97, respectively, P<0.05); when the total burn area was 86%-100% TBSA, the accuracy rates of the rehydration rates calculated by the pediatric ten-fold rehydration formula and the TWGB formula were 0 (0/1 335). When the rehydration rates calculated by the 2 pediatric emergency rehydration formulae were unreasonable, the rehydration rates calculated by the pediatric ten-fold rehydration formula were all higher than those of the TWGB formula. There were 93.07% (403/433), 5.77% (25/433), and 1.15% (5/433) patients in the 433 pediatric patients had total burn area of 30%-55%, 56%-85%, and 86%-100% TBSA, respectively, and the accuracy rate of the rehydration rate calculated using the pediatric ten-fold rehydration formula was 97.69% (423/433), which was significantly higher than 0 (0/433) of the TWGB formula (χ2=826.90, P<0.05). Conclusions: The application of the pediatric ten-fold rehydration formula to estimate the rehydration rate of pediatric patients after extensive burns is more accurate and convenient, superior to the TWGB formula, suitable for application by front-line healthcare workers that are not specialized in burns in pre-admission rescue of pediatric patients with extensive burns, and is worthy of promotion.

Impact of colloids or crystalloids in renal function assessed by NGAL and KIM-1 after hysterectomy: randomized controlled trial

Abstract Background Hydroxyethyl starches are colloids used in fluid therapy that may reduce volume infusion compared with crystalloids, but they can affect renal function in critical care patients. This study aims to assess renal effects of starches using renal biomarkers in the perioperative setting. Methods This prospective, controlled, randomized study compared Hydroxyethyl starch 6% (HES) with Ringer's lactate (RL) in hysterectomy. Each episode of mean arterial pressure (MAP) below 60 mmHg guided the fluid replacement protocol. The RL group received 300 mL bolus of RL solution while the HES group received 150 mL of HES solution. All patients received RL (2 mL.kg−1.h−1) intraoperatively to replace insensible losses. Blood and urine samples were collected at three time points (preoperatively, 24 hours, and 40 days postoperatively) to assess urinary NGAL and KIM-1, as primary outcome, and other markers of renal function. Results Seventy patients were randomized and 60 completed the study. The RL group received a higher crystalloid volume (1,277 ± 812.7 mL vs. 630.4 ± 310.2 mL; p= 0.0002) with a higher fluid balance (780 ± 720 mL vs. 430 ± 440 mL; p= 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%; p= 0.04) compared to the HES group. NGAL and KIM-1 did not differ between groups at each time point, however both biomarkers increased 24 hours postoperatively and returned to preoperative levels after 40 days in both groups. Conclusion HES did not increase renal biomarkers following open hysterectomy compared to RL. Moreover, HES provided better hemodynamic parameters using less volume, and reduced postoperative fluid balance and fluid overload.

Establishment and application of the tenfold rehydration formula for emergency resuscitation of adult patients after extensive burns / 中华烧伤杂志

Objective: To explore the scientificity and feasibility of the tenfold rehydration formula for emergency resuscitation of adult patients after extensive burns. Methods: A retrospective observational study was conducted. The total burn area (30%-100% total body surface area (TBSA)) and body weight (45-135 kg) of 170 adult patients (135 males and 35 females, aged (42±14) years) with extensive burns admitted to the Fourth Medical Center of PLA General Hospital from December 2016 to December 2019 were collected. The 6 461 pairs of simulated data obtained after pairing each body weight in 45 to 135 kg (programmed in steps of 1 kg) with each area in 30% to 100% TBSA (programmed in steps of 1%TBSA) were plugged into four recognized rehydration formulas--Parkland's formula, Brooke's formula, the 304th PLA Hospital formula, and the Third Military Medical University formula and two emergency rehydration formulas--the simplified first aid resuscitation plan for extensive burn patients proposed by the World Health Organization's Technical Working Group on Burns (TWGB, hereinafter referred to as the TWGB formula) and the tenfold rehydration formula proposed by the author of this article to calculate the rehydration rate within 8 hours after injury (hereinafter referred to as the rehydration rate), with results being displayed by a programming step of 10%TBSA for the total burn area. Taking the calculation results of four recognized rehydration formulas as the reasonable rehydration rate, the accuracy of rehydration rates calculated by two emergency rehydration formulas were calculated and compared. The body weight of 45-135 kg was divided into three segments by the results of maximum body weight at a reasonable rehydration rate calculated by the tenfold rehydration formula when the total burn area was 30% and 100% TBSA, respectively. The accuracy of rehydration rate calculated by two emergency rehydration formulas in each body weight segment was compared. When the rehydration rates calculated by two emergency rehydration formulas were unreasonable, the differences in rehydration rates between the two were compared. Statistical distribution of the aforementioned three body weight segments in the aforementioned 170 patients was counted. Using the total burn area and body weight data of the aforementioned 170 patients, the accuracy of rehydration rate calculated by two emergency rehydration formulas was calculated and compared as before. Data were statistically analyzed with McNemar test. Results: When the total burn area was 30%, 40%, 50%, 60%, 70%, 80%, 90%, and 100% TBSA, respectively, and the body weight was 45-135 kg, the rehydration rates calculated by two emergency rehydration formulas did not exceed the maximum of the calculated results of four recognized rehydration formulas; the rehydration rate calculated by the TWGB formula did not change accordingly with total burn area, while the rehydration rate calculated by the tenfold rehydration formula did not change accordingly with body weight. Substituting 6 461 pairs of simulated data showed that the accuracy of rehydration rate calculated by the tenfold rehydration formula was 43.09% (2 784/6 461), which was significantly higher than 2.07% (134/6 461) of the TWGB formula, χ2=2 404.80, P<0.01. When the body weights were 45-62 kg and 63-93 kg, the accuracy rates of rehydration rate calculated by the tenfold rehydration formula were 100% (1 278/1 278) and 68.42% (1 506/2 201), respectively, which were significantly higher than 0 (0/1 278) and 0.05% (1/2 201) of the TWGB formula, χ2=1 276.00, 1 501.01, P<0.01; when the body weight was 94-135 kg, the accuracy rate of rehydration rate calculated by the tenfold rehydration formula was 0 (0/2 982), which was significantly lower than 4.46% (133/2 982) of the TWGB formula, χ2=131.01, P<0.01. When the rehydration rates calculated by two emergency rehydration formulas were both unreasonable, the rehydration rate calculated by the tenfold rehydration formula was greater than that calculated by the TWGB formula in most cases, accounting for 79.3% (2 808/3 543). Among the 170 patients, the proportions of those weighing 45-62, 63-93, and 94-135 kg were 25.29% (43/170), 65.88% (112/170), and 8.82% (15/170), respectively. Among the 170 patients, the accuracy rate of rehydration rate calculated by the tenfold rehydration formula was 69.41% (118/170), which was significantly higher than 3.53% (6/170) of the TWGB formula, χ2=99.36, P<0.01. Conclusions: Applying the tenfold rehydration formula to calculate the emergency rehydration rate in adults after extensive burns is simpler than four recognized rehydration formulas, and is superior to the TWGB formula. The tenfold rehydration formula is suitable for the front-line medical staffs that are not specialized in burns in pre-admission rescue of adult patients with extensive burns, which is worth popularizing.

Experiencia en shock séptico en emergencias. Factores asociados a falta de respuesta a fluídos / Experience in septic shock in Emergencies. Factors associated with lack of response to fluid resuscitation

Introducción: La sepsis es una de las principales causas de muerte infantil a nivel mundial. Las guías de tratamiento utilizadas en nuestro servicio se basan en parámetros clínicos para un soporte hemodinámico temprano con énfasis en el uso de fluidos e inotrópicos guiados por metas clínicas. Objetivos: Describir las características epidemiológicas y clínicas en una cohorte de niños con diagnóstico de shock séptico (SS) en el área de emergencias, controlando tasa de respuesta a fluidos, mortalidad y su relación con las características de los pacientes. Materiales y métodos: Estudio observacional de cohorte prospectivo entre Julio del 2009 y Julio del 2010. Se incluyeron 83 pacientes entre 0 a 18 años que cumplieron con los criterios diagnósticos de SS. La respuesta a volumen se definió como: respondedores (RE) a los pacientes que solo requirieron expansión con volumen y no respondedores (nRE) a aquellos que requirieron inotrópicos luego de llegar a 60 ml/kg o aparición de signos de sobrecarga cardíaca. Resultados: 64% fueron varones con mediana de edad de 5,8 años (RIC 2-12). 71% presentaban alguna enfermedad crónica preexistente, siendo 40% pacientes oncológicos. El 25 % requirió asistencia respiratoria mecánica y 65% inotrópicos. La mediana de estadía hospitalaria fue 10 días (RIC 7-16 días). Un 35% fue RE. Solo la hipotensión al ingreso resultó ser factor de riesgo para nRE (p0,035), pero en el modelo multivariado no resultó estadísticamente significativo. El 8% de los pacientes fallecieron. Conclusiones: En nuestra población, los pacientes con enfermedades oncológicas representan un número importante de los casos de SS y posiblemente tengan una mayor mortalidad. La tasa de respuesta a volumen ocurrió en 35% de los casos. La hipotensión inicial constituye un probable factor de riesgo para nRE (AU)

Introduction: Sepsis is one of the main causes of childhood death worldwide. Treatment guidelines used at our department are based on clinical parameters for early hemodynamic support with emphasis on fluid resuscitation and inotropics use guided by clinical goals. Objectives: To describe the epidemiologic and clinical features of a cohort of children with septic shock (SS) seen at the emergency department evaluating response rate to fluid resuscitation and mortality related to patient characteristics. Materials and methods: A prospective, observational cohort study was conducted between July 2009 and July 2010. Overall, 83 patients between 0 and 18 years of age that met the diagnostic criteria of SS were included. Response to fluid resuscitation was defined as: responders (RE), those patients that only required volume expansion, and non-responders (nRE), those that required inotropes after having reached 60 ml/kg or appearance of signs of fluid overload. Results: 64% were boys; median age was 5.8 years (IQR 2-12); 71% had some type of preexisting chronic disease, consisting of cancer in 40%. Overall, 25% required mechanical ventilation and 65% inotropes. Median length of hospital stay was 10 days (IQR 7-16 days). 35% of the patients were RE. Only hypotension on admission was found to be a risk factor for nRE (p 0.035); however, in a multivariate model, this finding did not show to be statistically significant. Eight percent of the patients died. Conclusions: In our cohort, patients with cancer accounted for a large number of those who developed SS; in these patients mortality may be increased. Response rate to fluid resuscitation was 35%. Initial hypotension may be a risk factor for nRE.

Effects of magnesium sulfate and dioctyl sodium sulfosuccinate on fecal hydration, output and systemic hydration in healthy horses / [Efeitos do sulfato de magnésio e do dioctil-sulfossuccinato de sódio na hidratação e eliminação fecal e sobre a hidratação sistêmica de cavalos saudáveis]

Magnesium sulphate (MS) and dioctyl sodium sulphosuccinate (DSS) are laxative drugs frequently used for the treatment of impactions. The aim of this study was to compare the effects of MS and DSS in fecal hydration, output and systemic hydration in healthy horses. Five healthy horses received 3 treatments with a 21-day interval. Treatment 1 was performed with administration of 4 liters of warm water; treatment 2: administration of 4 liters of warm water associated with 1g/kg of MS; and treatment 3: administration of 4 liters of warm water associated with 20mg/kg DSS. General and specific physical examination of the digestive system were performed, alongside with packed cell volume and total plasma protein measurement, abdominal ultrasonography and quantification of the amount and hydration of feces, before and 6, 12, 24, 36 and 48 hours after the treatments. No adverse effects were observed. The administration of laxatives promoted greater fecal output and hydration without resulting in systemic dehydration, yet no differences were observed between treatments. The absence of adverse effects of DSS demonstrates the safety of its use as a laxative drug at a dose of 20mg/kg. Studies comparing the effects of the laxative drugs in horses with large colon impaction are needed.(AU)

O sulfato de magnésio (SM) e o dioctil-sulfossuccinato de sódio (DSS) são drogas laxativas frequentemente utilizadas no tratamento da compactação. O objetivo deste estudo foi comparar os efeitos do SM e do DSS na hidratação e eliminação fecal, e na hidratação sistêmica de cavalos saudáveis. Cinco cavalos receberam três tratamentos, com intervalo de 21 dias. O tratamento 1 consistiu na administração de quatro litros de água morna; o tratamento 2: administração de quatro litros de água morna associada a 1g/kg de SM; e o tratamento 3: administração de quatro litros de água morna associada a 20mg/kg de DSS. Foram realizados exames físicos gerais e específicos do trato digestivo, hematócrito e proteína plasmática total, ultrassonografia abdominal e mensuração da quantidade e hidratação das fezes antes e após seis, 12, 24, 36 e 48 horas dos tratamentos. Não foram observados efeitos adversos. A administração de ambos os laxantes promoveu maior produção fecal e hidratação, sem resultar em desidratação sistêmica, entretanto não houve diferença entre os tratamentos. A ausência de efeitos adversos do DSS demonstra a segurança de seu uso como medicamento laxante na dose de 20mg/kg. São necessários estudos que comparem o efeito dos laxantes em equinos portadores de compactação de cólon.(AU)

O comportamento da pressão arterial após elevação da pressão parcial positiva final pode auxiliar na determinação do status de fluido-responsividade em pacientes com choque séptico? / Can the behavior of blood pressure after elevation of the positive end-expiratory pressure help to determine the fluid responsiveness status in patients with septic shock?

RESUMO Objetivo: Avaliar se a diminuição da pressão arterial provocada pela elevação da pressão parcial positiva final corresponde à variação da pressão de pulso como indicador de fluido-responsividade. Métodos: Estudo de caráter exploratório que incluiu prospectivamente 24 pacientes com choque séptico ventilados mecanicamente e submetidos a três etapas de elevação da pressão parcial positiva final: de 5 para 10cmH2O (nível da pressão parcial positiva final 1), de 10 para 15cmH2O (nível da pressão parcial positiva final 2) e de 15 para 20cmH2O (nível da pressão parcial positiva final 3). Alterações da pressão arterial sistólica, da pressão arterial média e da variação da pressão de pulso foram avaliadas durante as três manobras. Os pacientes foram classificados como responsivos (variação da pressão de pulso ≥ 12%) e não responsivos a volume (variação da pressão de pulso < 12%). Resultados: O melhor desempenho para identificar pacientes com variação da pressão de pulso ≥ 12% foi observado no nível da pressão parcial positiva final 2: variação de pressão arterial sistólica de -9% (área sob a curva de 0,73; IC95%: 0,49 - 0,79; p = 0,04), com sensibilidade de 63% e especificidade de 80%. A concordância foi baixa entre a variável de melhor desempenho (variação de pressão arterial sistólica) e a variação da pressão de pulso ≥ 12% (kappa = 0,42; IC95%: 0,19 - 0,56). A pressão arterial sistólica foi < 90mmHg no nível da pressão parcial positiva final 2 em 29,2% dos casos e em 41,6,3% no nível da pressão parcial positiva final 3. Conclusão: Variações da pressão arterial em resposta à elevação da pressão parcial positiva final não refletem de modo confiável o comportamento da variação da pressão de pulso para identificar o status da fluido-responsividade.

Abstract Objective: To evaluate whether the decrease in blood pressure caused by the increase in the positive end-expiratory pressure corresponds to the pulse pressure variation as an indicator of fluid responsiveness. Methods: This exploratory study prospectively included 24 patients with septic shock who were mechanically ventilated and subjected to three stages of elevation of the positive end-expiratory pressure: from 5 to 10cmH2O (positive end-expiratory pressure level 1), from 10 to 15cmH2O (positive end-expiratory pressure level 2), and from 15 to 20cmH2O (positive end-expiratory pressure level 3). Changes in systolic blood pressure, mean arterial pressure, and pulse pressure variation were evaluated during the three maneuvers. The patients were classified as responsive (pulse pressure variation ≥ 12%) or unresponsive to volume replacement (pulse pressure variation < 12%). Results: The best performance at identifying patients with pulse pressure variation ≥ 12% was observed at the positive end-expiratory pressure level 2: -9% systolic blood pressure variation (area under the curve 0.73; 95%CI: 0.49 - 0.79; p = 0.04), with a sensitivity of 63% and specificity of 80%. Concordance was low between the variable with the best performance (variation in systolic blood pressure) and pulse pressure variation ≥ 12% (kappa = 0.42; 95%CI: 0.19 - 0.56). The systolic blood pressure was < 90mmHg at positive end-expiratory pressure level 2 in 29.2% of cases and at positive end-expiratory pressure level 3 in 41.63% of cases. Conclusion: Variations in blood pressure in response to the increase in positive end-expiratory pressure do not reliably reflect the behavior of the pulse pressure as a measure to identify the fluid responsiveness status.

Pulse pressure variation guided fluid therapy during kidney transplantation: a randomized controlled trial / Reposição de volume orientada pela variação da pressão de pulso durante transplante renal: estudo randomizado controlado

Abstract Purpose: Kidney transplantation is the gold-standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. Methods: We conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the "PPV" group received fluids whenever PPV was higher than 12%, patients in the "free fluid" group received fluids following our institutional standard care protocol for kidney transplantations (10 mL.kg-1. h-1). Results: Urinary output was similar at every time-point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. Conclusion: PPV guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.

Resumo Objetivo: Transplante renal é o tratamento padrão-ouro na doença renal em estágio terminal. Embora diferentes variáveis hemodinâmicas, tais como pressão venosa central e pressão arterial média, têm sido usadas para orientar a estratégia de reposição volêmica durante a cirurgia, a melhor estratégia ainda não foi determinada. A Variação da Pressão de Pulso (VPP) durante o ciclo respiratório é reconhecida como um bom preditor da resposta à infusão de volume para otimização hemodinâmica perioperatória no centro cirúrgico. O objetivo do estudo foi estudar se a estratégia de reposição de volume orientada por VPP é melhor do que a estratégia liberal de reposição de volume durante cirurgia de transplante renal. O principal objetivo do estudo foi identificar diferença no débito urinário na primeira hora do pós-operatório. Método: Realizamos estudo prospectivo, unicego, randomizado, controlado. Incluímos 40 pacientes submetidos a transplante renal de doador cadáver. Pacientes randomizados para o Grupo VPP receberam volume quando a VPP estava acima de 12%, e os pacientes no Grupo Reposição Liberal receberam volume de acordo com o nosso protocolo institucional padrão de assistência para transplante renal (10 mL.kg-1.h-1). Resultados: O débito urinário foi semelhante em todos os tempos nos dois grupos, a ureia foi estatisticamente diferente a partir do terceiro dia do pós-operatório com pico no quarto dia do pós-operatório e a creatinina apresentou tendência semelhante, tornando-se estatisticamente diferente a partir do segundo dia do pós-operatório. Ureia, creatinina e débito urinário não estavam diferentes na alta hospitalar. Conclusões: A terapia orientada por VPP durante transplante renal melhorou de forma significativa os níveis de ureia e creatinina na primeira semana pós-transplante renal.

Vena cava inferior como factor predictor del shock en trauma: medición ecográfica / Inferior vena cava as a predictor of shock in trauma patients: sonographic measurement

Resumen Objetivo Establecer la medición ecográfica del diámetro de la vena cava inferior como factor predictor del shock en pacientes politraumatizados. Materiales y Método Estudio de corte transversal donde se determinó la medición ecográfica de la vena cava inferior a 40 pacientes que ingresaron a la Unidad de Politraumatizados (UPT) del Hospital General del Este "Dr. Domingo Luciani", en el período entre enero y abril de 2018. Se seleccionaron 2 grupos; el grupo 1: pacientes en shock , aquellos con tensión arterial sistólica menor a 90 mm Hg al ingreso, y el grupo 2: pacientes controles que mantuvieron cifras tensionales normales. El estudio de imagen de la vena cava inferior se realizó con el equipo de ecografía ALOKA prosound SSD-a5 y con el ultrasonido portátil MicroMaxx SonoSite , en el cual se midió el índice de colapsabilidad. Los hallazgos se registraron en la hoja de recolección de datos. El análisis estadístico se hizo con la prueba de t de student para muestras independientes y la valoración de puntos de corte diagnóstico se hizo con la prueba de ROC. Resultados La media del Índice de colapsabilidad (IC) de la VCI para el grupo control y de shock fue de 26 ± 12,7% y de 58,5 ± 5,9%, respectivamente; El índice de colapsabilidad fue > 50% en todos los pacientes del grupo de shock . Conclusiones La medición del diámetro de la VCI es un predictor de shock , siendo el IC el parámetro más sensible y específico.

Aim To establish the sonographic measurement of the diameter of the inferior vena cava as a predictor of shock in trauma patients. Materials and Method A cross-sectional study to determined the sonographic measurement of the inferior vena cava to 40 patients attended at Hospital Domingo Luciani trauma unit, in the period between January and April of 2018. Two groups were selected; group 1: shock patients, those with systolic blood pressure lower than 90 mm Hg, and the group 2: control patients that kept normal blood pressure. The image study of the inferior vena cava was carried out with the ALOKA prosound ultrasound equipment SSD a5 and with the portable ultrasound MicroMaxx SonoSite, in which the collapsibility index was measured. The findings were recorded in the data collection sheet. The statistical analysis proposed for the comparison of averages was made with the student's t-test for independent samples and the assessment of diagnostic cut-off points was made with a ROC curve. Results the mean of collapsability index of de IVC for control and shock group were 26 ± 12,7% and 58,5 ± 5,9%, respectively; The collapsability index (CI) was > 50% in all patients of shock group. Conclusions The measurement of the ICV diameter is a predictor of shock, being the IC the most sensitive and specific parameter.

Beyond ventilatory support: challenges in general practice and in the treatment of critically Ill children and adolescents with SARS-CoV-2 infection

SUMMARY Severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2 infection) is a new challenge for all countries, and children are predisposed to acquire this disease. Some studies have demonstrated more severe diseases in adults, but critically ill pediatric patients have been described in all ages. Pulmonary involvement is the major feature, and ventilatory support is common in critical cases. Nevertheless, other very important therapeutic approaches must be considered. In this article, we reviewed extensively all recent medical literature to point out the main clinical attitudes to support these pediatric patients during their period in respiratory support. Radiologic findings, fluid therapy, hemodynamic support, use of inotropic/vasopressors, nutritional therapy, antiviral therapy, corticosteroids, antithrombotic therapy, and immunoglobulins are analyzed to guide all professionals during hospitalization. We emphasize the importance of a multi-professional approach for adequate recovery.

RESUMO A síndrome respiratória aguda grave (SRAG) pelo novo coronavirus (SARS-CoV-2) é um novo desafio para todos os países e crianças estão predispostas a adquirir a doença. Alguns estudos demonstraram quadros mais graves em adultos, mas crianças criticamente doentes foram descritas em todas as idades. O envolvimento pulmonar é a principal característica e a necessidade de suporte ventilatório é comum nos casos mais graves. Entretanto, outras abordagens terapêuticas importantes devem ser consideradas. Nesse artigo revisamos extensamente a literature médica até o momento a fim de citar os principais recursos terapêuticos para o manejo dos pacientes pediátricos durante o período de suporte ventilatório. Achados radiológicos, terapia fluídica, terapia antiviral, o uso de corticosteroides, terapia antitrombótica e o uso de imunoglobulinas foram analisados a fim de guiar os profissionais durante o período de hospitalização desses pacientes. Nós reforçamos a importância de uma abordagem multiprofissional para recuperação adequada.

La administración de ondansetrón no mejora la evolución de los niños con gastroenteritis aguda sin deshidratación / Administration of ondansetron does not improve the course of children with acute gastroenteritis without dehydration

Sobre la base de una viñeta clínica de un niño con gastroenteritis aguda sin deshidratación, el autor de este artículo realiza una búsqueda bibliográfica para revisar la evidencia que avala el uso de ondansetrón para tratar sus vómitos, práctica bastante común en instituciones con acceso a este fármaco en sus centrales de emergencia. Luego de dicha búsqueda, el autor concluye que en niños con gastroenteritis aguda sin deshidratación, la administración de ondansetrón no reduce la necesidad de hidratación intravenosa ni la frecuencia ni la severidad de los vómitos. (AU)

Based on a clinical vignette of a child with acute gastroenteritis without dehydration, the author of this article performs a literature search to review the evidence supporting the use of ondansetron to treat his vomiting, a fairly common practice in institutions with access to this drug in their emergency rooms. After this search, the author concludes that in children with acute gastroenteritis without dehydration, the administration of ondansetron does not reduce the need for intravenous hydration or the frequency or severity of vomiting. (AU)

A sobrecarga intravenosa de fluidos e sódio pode contribuir para a menor infusão de nutrição enteral em pacientes críticos / Intravenous overload of fluids and sodium may contribute to the lower infusion of enteral nutrition in critically ill patients

RESUMO Objetivo: Avaliar os efeitos da administração intravenosa de fluidos e sódio no primeiro dia de internação com a infusão de nutrição enteral em pacientes de terapia intensiva. Métodos: Estudo de coorte prospectivo realizado com pacientes críticos, não cirúrgicos, em ventilação mecânica internados pelo menos há 5 dias com nutrição enteral. Investigaram-se a quantidade de fluidos e sódio administrados por via venosa no primeiro dia e o volume de nutrição enteral infundido nos primeiros 5 dias. Comparou-se o volume de fluidos intravenosos do primeiro dia > 35mL/kg ou ≤ 35mL/kg de peso corporal e de sódio (acima ou abaixo do percentil 25), com o total de nutrição enteral infundida. Resultados: Estudaram-se 86 pacientes com média (± desvio padrão) de 65 ± 17 anos, sendo 54,7% do sexo feminino. Foram administrados, no primeiro dia, 3.393,7 ± 1.417,0mL de fluidos (48,2 ± 23,0mL/kg) e 12,2 ± 5,1g de sódio. Cinquenta e oito (67,4%) pacientes receberam mais de 35mL/kg de fluidos. Em 5 dias, foram ofertados 67 ± 19,8% (2.993,8 ± 1.324,4mL) da nutrição enteral. Os pacientes que receberam > 35mL/kg de fluidos intravenosos também receberam menos nutrição enteral em 5 dias (2.781,4 ± 1.337,9 versus 3.433,6 ± 1.202,2mL; p = 0,03) versus quem recebeu ≤ 35mL/kg. Pacientes com infusão de sódio intravenoso acima do percentil 25 (≥ 8,73g) no primeiro dia receberam menos volume de nutrição enteral em 5 dias (2.827,2 ± 1.398,0 versus 3.509,3 ± 911,9mL; p = 0,02). Conclusão: Os resultados deste estudo apoiam o pressuposto de que a administração de fluidos intravenosos no primeiro dia de internação > 35mL/kg e de sódio ≥ 8,73g pode contribuir para a menor infusão de nutrição enteral em pacientes críticos.

ABSTRACT Objective: To evaluate the effects of intravenous infusion of fluids and sodium on the first day of admission on infusion of enteral nutrition in the first 5 days in intensive care patients. Methods: A prospective cohort study was conducted with critical nonsurgical patients admitted for at least 5 days who were on mechanical ventilation and receiving enteral nutrition. The amount of intravenous fluids and sodium infused on the first day and the volume of enteral nutrition infused in the first 5 days were investigated. The volume of intravenous fluids > 35mL/kg or ≤ 35mL/kg of body weight and sodium (above or below the 25th percentile) infused on the first day was compared with infused enteral nutrition. Results: A total of 86 patients were studied, with a mean (± standard deviation) of 65 ± 17 years, of which 54.7% were female. On the first day, 3,393.7 ± 1,417.0mL of fluid (48.2 ± 23.0mL/kg) and 12.2 ± 5.1g of sodium were administered. Fifty-eight (67.4%) patients received more than 35mL/kg of fluids. In 5 days, 67 ± 19.8% (2,993.8 ± 1,324.4mL) of the prescribed enteral nutrition was received. Patients who received > 35mL/kg of intravenous fluids also received less enteral nutrition in 5 days (2,781.4 ± 1,337.9 versus 3,433.6 ± 1,202.2mL; p = 0.03) versus those who received ≤ 35mL/kg. Patients with intravenous sodium infusion above the 25th percentile (≥ 8.73g) on the first day received less enteral nutrition volume in 5 days (2,827.2 ± 1,398.0 versus 3,509.3 ± 911.9mL; p = 0.02). Conclusion: The results of this study support the assumption that the administration of intravenous fluids > 35mL/kg and sodium ≥ 8.73g on the first day of hospitalization may contribute to the lower infusion of enteral nutrition in critically ill patients.

Hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs dehydrated by water restriction: Part 1 / Soluções eletrolíticas enterais hipotônicas administradas por sonda nasoesofágica em fluxo contínuo em cães desidratados por restrição hídrica: Parte 1

The present study assessed and compared the effects of hypotonic enteral electrolyte solutions administered by nasoesophageal tube in continuous flow in dogs submitted to water restriction on packed cell volume; total serum protein and serum osmolarity concentrations; blood volume; plasma glucose and lactate levels; blood gas analysis, anion gap, and strong ion difference. Six adult dogs were used (four males and two females). All animals were submitted to both proposed treatments in a crossover design 6×2. The treatments were as follows: ESmalt consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g maltodextrin that were diluted in 1.000mL water (measured osmotic concentration of 215mOsm L−1) and ESdext consisting of 5g sodium chloride, 1g potassium chloride, 1g calcium acetate, 0.2g magnesium pidolate, and 9.6g dextrose that were diluted in 1.000mL water (measured osmotic concentration of 243mOsm L−1). All solutions were administered at 15ml kg−1 h−1 for 4 hours. Both solutions increased the plasma volume in dehydrated dogs without causing adverse effects. However, ESmalt was more effective in promoting the increase in blood volume.(AU)

O presente estudo avaliou e comparou os efeitos de soluções eletrolíticas enterais hipotônicas, administradas por sonda nasoesofágica em fluxo contínuo em cães submetidos a restrição hídrica, sobre o hematócrito, proteínas totais séricas, osmolaridade sérica, volemia, glicose e lactato plasmáticos, hemogasometria, ânion gap e DIF. Foram utilizados seis cães adultos (quatro machos e duas fêmeas). Todos os animais foram submetidos aos dois tratamentos propostos, em um delineamento crossover 6×2. Os tratamentos foram os seguintes: SEmalt - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de maltodextrina, diluídos em 1.000mL de água (osmolaridade mensurada: 215mOsm L -1 ); SEdext - 5g de cloreto de sódio, 1g de cloreto de potássio, 1g de acetato de cálcio, 0,2g de pidolato de magnésio e 9,6g de dextrose, diluídos em 1.000mL de água (osmolaridade mensurada: 243mOsm L -1 ). Todas as soluções foram administradas no volume de 15mL kg -1 hora -1 , durante quatro horas, em fluxo contínuo. Ambas as soluções aumentaram o volume plasmático em cães desidratados, sem gerar o aparecimento de efeitos adversos. Porém, a SEmalt foi mais eficaz em promover a expansão da volemia.

Reporte de caso de enfermedad mano-pie-boca con lesiones mucocutáneas que evolucionan a necrosis / A case report of hand, foot, and mouth disease with necrotizing mucocutaneous lesions

La enfermedad de mano-pie-boca es una patología originada en la mayoría de los casos por el virus coxsackie A tipo 16, aunque también puede ser ocasionada por otras cepas de la familia de los coxsackievirus. Dicho virus se propaga principalmente por vía fecal oral y, en menor proporción, por secreciones. Se presenta principalmente en verano, siendo frecuente en niños menores de 10 años. Dentro de dicha enfermedad las lesiones mucocutáneas que evolucionen en necrosis son poco frecuentes, constituyéndose en una complicación severa que requiere hospitalización. En el presente artículo se reporta un caso con diagnóstico de enfermedad mano-pie-boca, que evolucionó hacia lesiones mucocutáneas necróticas, mostrando una respuesta favorable a una terapia de soporte de aciclovir, líquidos y electrolitos.

In most cases, the cause of hand, foot, and mouth disease (HFMD) is coxsackievirus A type 16. The infection can also be caused by other strains of coxsackievirus, spreading mainly by the oral-fecal route, while it is less likely to be transmitted through secretions. HFMD occurs mainly in summer and is more common in children under ten. Skin lesions develop during the disease but rarely become necrotic. When present, they are a severe complication requiring hospitalization. This paper reports the case of a patient with HFMD who developed necrotic mucocutaneous lesions that responded favorably to intravenous acyclovir, fluids, and electrolyte support therapy.

Uso do índice de perfusão para avaliar reatividade microvascular no choque séptico após ressuscitação volêmica / Perfusion index for assessing microvascular reactivity in septic shock after fluid resuscitation

RESUMO Objetivo: Os distúrbios microcirculatórios estão implicados no prognóstico do choque séptico. A hiporresponsividade microvascular pode ser avaliada por meio do índice de perfusão, derivado da oximetria de pulso e hiperemia reativa. Com utilização do índice de perfusão, investigamos a hiperemia reativa e sua relação com a perfusão periférica e os parâmetros clínico-hemodinâmicos no choque séptico. Métodos: Avaliaram-se 82 pacientes, 47 deles com choque séptico e 35 controles. Os exames foram realizados dentro de 24 horas após a admissão. O índice de perfusão foi avaliado antes e após uma oclusão do fluxo sanguíneo durante 3 minutos, utilizando-se análise de resposta temporal por 5 minutos. O índice de perfusão foi também avaliado nas fases hiperêmicas, principalmente com derivação de mecanismos mecanossensitivos (ΔIP0-60) e metabólicos (ΔIP60-120). Realizaram-se testes de correlação entre a hiperemia reativa e dados clínicos hemodinâmicos. Resultados: A hiperemia reativa, medida pelo índice de perfusão, foi significantemente mais baixa no choque séptico apenas até 45 segundos após a desinflação do manguito. No período restante, não houve diferenças estatisticamente significantes entre os grupos. Os picos de índice de perfusão foram similares entre os grupos, embora o pico tenha sido atingido de forma mais lenta no grupo séptico. Os valores de ΔIP0-60 foram mais baixos no choque [1% (-19% - -40%) versus 39% (6% - 75%); p = 0,001]. No entanto, o ΔIP60-120 foi similar entre os grupos [43% (18% - 93%) versus 48% (18% - 98%); p = 0,58]. O tempo até o pico do índice de perfusão se correlacionou de forma positiva com o SOFA e negativamente com os níveis de proteína C-reativa. O pico de índice de perfusão se correlacionou de forma positiva com as doses de vasopressores; os valores de ΔIP60-120 tiveram correlação positiva com o nível de proteína C-reativa e as doses de vasopressores. Não ocorreram outras correlações significantes. Conclusões: Este estudo com base no índice de perfusão sugere que o choque séptico promove hiporresponsividade vascular periférica, enquanto a reatividade vascular posterior é consideravelmente preservada. Estes resultados demonstram resposta hiperêmica periférica dependente do tempo e significante reserva isquêmica no choque séptico.

ABSTRACT Objective: Microcirculation disturbances are implicated in the prognosis of septic shock. Microvascular hyporesponsiveness can be assessed by an oximetry-derived perfusion index and reactive hyperemia. Using this perfusion index, we investigated reactive hyperemia and its relationship with peripheral perfusion and clinical-hemodynamic parameters in septic shock. Methods: Eighty-two patients were evaluated: 47 with septic shock and 35 controls. Tests were performed within 24 hours after admission. The perfusion index was evaluated before and after a 3-min blood flow occlusion using a time-response analysis for 5 min. The perfusion index was also evaluated in the hyperemic phases and was mainly derived by mechanosensitive (ΔPI0-60) and metabolic mechanisms (ΔPI60-120). Correlation tests were performed between reactive hyperemia and clinical-hemodynamic data. Results: Reactive hyperemia measured by the perfusion index was significantly lower in patients with septic shock, but this was only observed for the first 45 seconds after cuff-deflation. In the remaining period, there were no statistical differences between the groups. The peaks in the perfusion index were similar between groups, although the peak was reached more slowly in the septic group. Values of ΔPI0-60 were lower in shock [01% (-19% - -40%) versus 39% (6% - 75%); p = 0.001]. However, ΔPI60-120 was similar between the groups [43% (18% - 93%) versus 48% (18% - 98%); p = 0.58]. The time-to-peak of the perfusion index was correlated positively with the SOFA scores and negatively with C-reactive protein; the peak of the perfusion index was positively correlated with vasopressor doses; and the ΔPI60-120 values were positively correlated with C-reactive protein and vasopressor doses. No other significant correlations occurred. Conclusions: This perfusion index-based study suggests that septic shock promotes initial peripheral vascular hyporesponsiveness and preserves posterior vascular reactivity to a considerable degree. These results demonstrate a time-dependent peripheral hyperemic response and a significant ischemic reserve in septic shock.

Hiponatremia adquirida en el hospital: ¿influye el tipo de fluidoterapia en los niños ingresados a cuidados intensivos? / Hospital-acquired hyponatremia: Does the type of fluid therapy affect children admitted to intensive care?

Resumen: Introducción: Este estudio tuvo por objetivo valorar las diferencias entre el tipo de fluidoterapia ini cial utilizada (sueros isotónicos o hipotónicos) en el desarrollo de hiponatremia, valores de cloro y to lerancia de las vías venosas. Pacientes y Método: Estudio retrospectivo de cohortes en una Unidad de Cuidados Intensivos Pediátricos (UCIP) de un hospital terciario. Se incluyeron niños menores de 15 años ingresados durante el primer semestre de los años 2010 y 2013, que recibieron fluidoterapia in travenosa, excluyéndose los sometidos a cirugía cardiaca, trasplantados renales y aquellos con ingreso inferior a 24 h. Se recogieron datos epidemiológicos, de comorbilidad y relacionados con el ingreso, tipo de suero recibido, valores de sodio y cloro en las primeras 72 h y la incidencia de extravasaciones de vías periféricas. Resultados: Se incluyeron 111 niños: 68 (61,3%) recibieron líquidos hipotónicos y 43 (38,7%) isotónicos. No hubo diferencias respecto a la patología y gravedad, ni tampoco en el volumen de líquidos recibido. Entre los pacientes que recibieron sueros hipotónicos, 28 (41,2%) pre sentaron hiponatremia, siendo esta moderada (Na <130 mEq/kg) en 11 de ellos, en comparación con 8 niños (18,6%) entre los que recibieron sueros isotónicos, registrando hiponatremia moderada solo en un caso (p=0,027). No se registró ningún caso de hipernatremia, ni hubo diferencias en los valores de cloro plasmático. Tampoco se objetivó mayor frecuencia de pérdida del acceso venoso utilizando la fluidoterapia isotónica (4,7% vs. 7,4%, p=0,704). Conclusión: El uso de líquidos iniciales isotóni cos en niños hospitalizados en UCIP se asocia con menor incidencia y gravedad de hiponatremia, sin cambio en la cloremia y es bien tolerado por las vías venosas periféricas.

Abstract: Introduction: The objective of this study was to evaluate the association between the type of initial fluid therapy used (isotonic or hypotonic solutions) and the development of hyponatremia, the plas ma chlorine values and the tolerance of venous access. Patients and Method: Retrospective cohort study in a Pediatric Intensive Care Unit (PICU) of a high complexity hospital. There were included children younger than 15 years old hospitalized during the first semester of 2010 and 2013 who recei ved intravenous maintenance fluid therapy, excluding patients undergoing cardiac surgery, kidney transplant and admissions that lasted less than 24 hours. Epidemiological, comorbidity and admis sion-related data were collected, including type of solution received, sodium and chlorine values in the first 72 hours of hospitalization and the incidence of extravasation of peripheral intravenous lines. Results: 111 children were included; 68 children (61.3%) were treated with hypotonic solutions and 43 (38.7%) with isotonic solutions. There were no differences in pathology and severity, and also in the volume of fluid received. Among the patients who received hypotonic solutions, 28 (41.2%) de veloped hyponatremia, wich was moderate (Na <130 mEq/Kg) in 11 cases, compared with 8 children (18.6%) who received isotonic solutions, with only one case of moderate hyponatremia (p = 0.027). No cases of hypernatremia were recorded, and there were no differences in plasma chlorine values. There was also no increased frequency of venous access loss in patients treated with isotonic solutions (4.7% versus 7.4%, p = 0.704). Conclusion: Treatment with initial isotonic solutions in children hos pitalized in PICU is associated with a lower incidence and severity of hyponatremia, without changes in the plasma chlorine values and it is well tolerated by peripheral intravenous lines.

Clinical trial for the control of water intake of patients undergoing hemodialysis treatment / Ensaio clínico para o controle da ingestão hídrica de pacientes em tratamento hemodialítico * / Ensayo clínico para el control de la ingestión hídrica de pacientes en tratamiento hemodialítico

ABSTRACT Objective: to analyze the impact of an educational and motivational intervention for patients with a chronic kidney disease, undergoing hemodialysis treatment, on the control of fluid intake during interdialytic periods. Method: a quasi-experimental, non-randomized clinical trial with patients from a Nephrological Unit of the State of São Paulo. Participants were included in two groups: Control Group with 106 patients and Intervention Group with 86 patients, totaling 192 participants. The used intervention was an educational and motivational video to control liquid intake, based on the Bandura's Theory. The measure of control of water intake was the percentage of lost weight, also considered the variable outcome of the research. For the data analysis, descriptive analyses and regression analysis of the Inflated Beta Model were used. Results: patients who participated in the intervention had a decrease in the pattern of weight gain in interdialytic periods, with a 3.54 times more chance of reaching the goal of 100% of weight loss when compared to participants from the control group. Conclusion: the educational and motivational intervention was effective in reducing the percentage of weight loss in patients undergoing hemodialysis. Brazilian Clinical Trials Registry (ReBEC) under the opinion RBR-4XYTP6.

RESUMO Objetivo: analisar o impacto de uma intervenção educativa e motivacional para pacientes com doença renal crônica em tratamento hemodialítico, no controle do consumo de líquidos, nos períodos interdialíticos. Método: estudo quase experimental do tipo ensaio clínico não randomizado, com pacientes de uma Unidade Nefrológica no interior do Estado de São Paulo. Os participantes foram inseridos em dois grupos: Grupo Controle com 106 pacientes e Grupo Intervenção com 86 pacientes, totalizando 192 participantes do estudo. A intervenção utilizada tratou-se de um vídeo educativo e motivacional para controle do consumo de líquidos, baseado na Teoria de Bandura. A medida de controle da ingestão hídrica foi o percentual de peso perdido, também considerado a variável desfecho da pesquisa. Para a análise dos dados foram utilizadas análises descritivas e análise de regressão do Modelo Beta Inflacionado. Resultados: os pacientes que participaram da intervenção apresentaram diminuição no padrão de ganho de peso nos períodos interdialíticos, com 3,54 vezes mais chance de atingir a meta de 100% de perda de peso, comparados aos participantes do grupo controle. Conclusão: a intervenção educativa e motivacional mostrou-se efetiva na diminuição do porcentual de perda de peso dos pacientes em hemodiálise. Registro Brasileiro de Ensaios Clínicos (ReBEC), sob o parecer RBR-4XYTP6.

RESUMEN Objetivo: analizar el impacto de una intervención educativa y motivacional para pacientes con enfermedad renal crónica en tratamiento hemodialítico, en el control del consumo de líquidos, en los periodos interdialíticos. Método: estudio casi experimental del tipo ensayo clínico no aleatorio, con pacientes de una Unidad Nefrológica en el interior del Estado de São Paulo. Los participantes fueron inseridos en dos grupos: Grupo Control con 106 pacientes y Grupo Intervención con 86 pacientes, totalizando 192 participantes del estudio. La intervención utilizada se trató de un video educativo y motivacional para el control del consumo de líquidos, basado en la Teoría de Bandura. La medida de control de la ingestión hídrica fue el porcentaje de peso perdido, también considerado la variable de resultado de la investigación. Para el análisis de los datos fueron utilizados análisis descriptivos y análisis de regresión del Modelo Beta aumentado. Resultados: los pacientes que participaron de la intervención presentaron disminución en el patrón de ganancia de peso en los periodos interdialíticos, con 3,54 veces más chances de alcanzar la meta de 100% de pérdida de peso, comparados a los participantes del grupo de control. Conclusión: la intervención educativa y motivacional se mostró efectiva en la disminución del porcentaje de pérdida de peso de los pacientes en hemodiálisis. Registro Brasileño de Ensayos Clínicos (ReBEC), bajo el dictamen RBR-4XYTP6.