Tourniquet use for civilian extremity hemorrhage: systematic review of the literature / Uso de torniquete nas hemorragias de extremidades na população civil: revisão sistemática da literatura

ABSTRACT Introduction: extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. Methods: a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. Results: of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. Conclusions: TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.

RESUMO Introdução: o uso de torniquete em extremidades (TQ) aumentou no ambiente civil; os resultados benéficos observados nas forças armadas influenciaram a aceitação por equipes de pré-hospitalar (PH) assim como pela população leiga. Esta revisão teve como objetivo analisar os tipos de TQ de extremidades usados em ambiente civil, local da lesão, indicações e complicações. Métodos: revisão sistemática foi conduzida com base em artigos originais publicados no PubMed, Embase e Cochrane seguindo as diretrizes do PRISMA de 2010 a 2019. Extração de dados focada no uso de TQ de extremidade para controle de hemorragia em ambiente civil, dados demográficos, tipo de estudo e duração, mecanismo de lesão, indicações de uso, local da lesão, tipo de TQ, tempo de TQ e complicações. Resultados: dos 1.384 artigos identificados, 14 foram selecionados para revisão com total de 3.912 vítimas civis com hemorragia nas extremidades e 3.522 colocações de extremidades TQ analisadas. A maioria foi aplicado em pacientes do sexo masculino (79%), com trauma contuso ou penetrante. Entre as indicações estavam choque hemorrágico, suspeita de lesões vasculares, sangramento contínuo e amputações traumáticas parciais ou completas. A aplicação na extremidade superior foi o local de aplicação mais comum (56%), quase todos aplicados a uma única extremidade (99%), e apenas 0,6% requereram aplicações nas extremidades superior e inferior. 80% dos TQs aplicados eram dispositivos comerciais e 20% improvisados. Conclusões: o uso de TQ em ambientes civis está associado a traumas. Os TQs comerciais são mais utilizados, com tempo menor que uma hora de uso e poucas complicações.

Comportamiento de la hemorragia digestiva alta en el quinquenio 2009 a 2013 / Behavior of the high digestive bleeding in the five-year period 2009-2013

Introducción: la hemorragia digestiva alta constituye un problema frecuente de salud en el mundo; así se comporta en Cuba, en la provincia Matanzas y en el hospital de estudio. Actualmente es considerada como causa mayor de morbimortalidad. Objetivo: determinar el comportamiento de la hemorragia digestiva alta en el Hospital Militar de Matanzas. Materiales y Métodos: se realizó una investigación descriptiva, en un periodo de cinco años que incluyó a todos los pacientes ingresados con ese diagnóstico, y los que durante su ingreso por otra causa presentaron episodios de hemorragia. El índice de Rockall permitió evaluar la necesidad de cirugía, recidiva y mortalidad. Resultados: la mayoría de los pacientes pertenecieron al grupo de riesgo intermedio. Los hombres fueron los más afectados, el grupo de tercera edad presentó mayor incidencia. La gastritis hemorrágica fue la primera causa de sangrado. La hipertensión arterial resultó ser el factor de riesgo relevante y el tabaquismo el hábito tóxico más frecuente. Conclusiones: como beneficio relevante se demostró la importancia de la endoscopia precoz para el diagnóstico de la causa, tratamiento y pronóstico de la hemorragia. Se observó una buena correlación entre el pronóstico del paciente al ingreso y su estado al final del tratamiento (AU).

Introduction: the high digestive hemorrhage is a frequent health problem in the world; it behaves the same in Cuba, in the province of Matanzas and in the hospital where the study was carried out. Currently it is considered a major cause of morbi-mortality. Objective: to determine the behavior of the high digestive bleeding in the Military Hospital of Matanzas. Materials and Methods: a descriptive research was carried out in a five-year period. It included all the patients admitted with that diagnosis and those who presented episodes of hemorrhage even if they were admitted by any other cause. The Rockall index allowed to assess the necessity of surgery, the recidivism and mortality. Results: most of the patients belonged to the intermediate risk group. Male patients were the most affected one; the group of elder people showed higher incidence. Hemorrhagic gastritis was the first cause of bleeding. Arterial hypertension was the relevant risk factor and smoking the most frequent toxic habit. Conclusions: as a relevant benefit it was showed the importance of precocious endoscopy for the diagnosis of the hemorrhage cause, treatment and prognosis. It was observed a good correlation between the patient´s prognosis at the admission and his status at the end of the treatment (AU).

Fondaparinux versus Enoxaparin - Which is the Best Anticoagulant for Acute Coronary Syndrome? - Brazilian Registry Data / Fondaparinux versus Enoxaparina - Qual o Melhor Anticoagulante para Síndrome Coronariana Aguda? - Dados de um Registro Brasileiro

Abstract Background: Recent studies have shown fondaparinux's superiority over enoxaparin in patients with non-ST elevation acute coronary syndrome (ACS), especially in relation to bleeding reduction. The description of this finding in a Brazilian registry has not yet been documented. Objective: To compare fondaparinux versus enoxaparin in in-hospital prognosis of non-ST elevation ACS. Methods: Multicenter retrospective observational study. A total of 2,282 patients were included (335 in the fondaparinux group, and 1,947 in the enoxaparin group) between May 2010 and May 2015. Demographic, medication intake and chosen coronary treatment data were obtained. Primary outcome was mortality from all causes. Secondary outcome was combined events (cardiogenic shock, reinfarction, death, stroke and bleeding). Comparison between the groups were done through Chi-Square test and T test. Multivariate analysis was done through logistic regression, with significance values defined as p < 0.05. Results: With regards to treatment, we observed the performance of a percutaneous coronary intervention in 40.2% in the fondaparinux group, and in 35.1% in the enoxaparin group (p = 0.13). In the multivariate analysis, we observed significant differences between fondaparinux and enoxaparin groups in relation to combined events (13.8% vs. 22%. OR = 2.93, p = 0.007) and bleeding (2.3% vs. 5.2%, OR = 4.55, p = 0.037), respectively. Conclusion: Similarly to recently published data in international literature, fondaparinux proved superior to enoxaparin for the Brazilian population, with significant reduction of combined events and bleeding.

Resumo Fundamento: Estudos recentes têm apresentado superioridade do fondaparinux em relação à enoxaparina em pacientes com síndrome coronariana aguda (SCA) sem supradesnivelamento de ST, principalmente relacionada à redução de sangramentos. A descrição desse achado em registro brasileiro ainda não foi documentada. Objetivo: Comparar fondaparinux versus enoxaparina no prognóstico intrahospitalar em SCA sem supradesnivelamento de ST. Métodos: Estudo retrospectivo, multicêntrico e observacional. Foram incluídos 2.282 pacientes (335 no grupo fondaparinux e 1.947 no grupo enoxaparina) entre maio de 2.010 e maio de 2.015. Foram obtidos dados demográficos, medicações utilizadas e tratamento coronariano adotado. O desfecho primário foi mortalidade por todas as causas. O desfecho secundário foi eventos combinados (choque cardiogênico, reinfarto, morte, acidente vascular cerebral e sangramentos). A comparação entre os grupos foi realizada por meio de Q-quadrado e teste-T. A análise multivariada foi realizada por regressão logística, sendo considerado significativo p < 0,05. Resultados: Em relação ao tratamento, observou-se realização de intervenção coronária percutânea em 40,2% no grupo fondaparinux e 35,1% no grupo enoxaparina (p = 0,13). Na análise multivariada, observaram-se diferenças significativas entre os grupos fondaparinux e enoxaparina em relação a eventos combinados (13,8% vs. 22%, OR = 2,93, p = 0,007) e sangramentos (2,3% vs. 5,2%, OR = 4,55, p = 0,037), respectivamente. Conclusão: Semelhante aos dados recentemente publicados na literatura mundial, fondaparinux mostrou-se superior à enoxaparina para a população brasileira, com redução significativa de eventos combinados e sangramentos.

Early Sodium and Fluid Intake and Severe Intraventricular Hemorrhage in Extremely Low Birth Weight Infants

Hypernatremic dehydration is an important cause of intracranial hemorrhage. A possible association of intraventricular hemorrhage (IVH) with hypernatremia and/or high sodium intake has been suggested in preterm infants. To investigate the associations of early fluid and sodium intake or serum sodium concentrations with severe intraventricular hemorrhage (IVH) in extremely low birth weight (ELBW) infants, we reviewed the medical records of 169 inborn ELBW infants. Daily fluid and sodium intake, urine output, weight loss and serum sodium concentration during the first 4 days of life were obtained. Patients were divided into the severe IVH (grade 3/4) and the control (no or grade 1/2 IVH) group. The maximum serum sodium concentration and the incidence of hypernatremia did not differ between the two groups. Related to the fluid balance and sodium intake, the risk for severe IVH was strongly associated with total fluid and sodium intake during the initial four days of life. With respect to the fluids other than transfusion, severe IVH can be discriminated only by sodium intake but not by fluid intake. Large randomized controlled trials are required to clarify the causal relationship between the early sodium intake and severe IVH in ELBW infants.

Early Sodium and Fluid Intake and Severe Intraventricular Hemorrhage in Extremely Low Birth Weight Infants

Hypernatremic dehydration is an important cause of intracranial hemorrhage. A possible association of intraventricular hemorrhage (IVH) with hypernatremia and/or high sodium intake has been suggested in preterm infants. To investigate the associations of early fluid and sodium intake or serum sodium concentrations with severe intraventricular hemorrhage (IVH) in extremely low birth weight (ELBW) infants, we reviewed the medical records of 169 inborn ELBW infants. Daily fluid and sodium intake, urine output, weight loss and serum sodium concentration during the first 4 days of life were obtained. Patients were divided into the severe IVH (grade 3/4) and the control (no or grade 1/2 IVH) group. The maximum serum sodium concentration and the incidence of hypernatremia did not differ between the two groups. Related to the fluid balance and sodium intake, the risk for severe IVH was strongly associated with total fluid and sodium intake during the initial four days of life. With respect to the fluids other than transfusion, severe IVH can be discriminated only by sodium intake but not by fluid intake. Large randomized controlled trials are required to clarify the causal relationship between the early sodium intake and severe IVH in ELBW infants.

Femoral versus Radial Access in Primary Angioplasty. Analysis of the ACCEPT Registry / Via de Acesso Femoral versus Radial na Angioplastia Primária. Análise do Registro ACCEPT

Background: The radial access provides a lower risk of bleeding and vascular complications related to the puncture site in comparison to the femoral access. Recent studies have suggested a reduction in mortality associated with the radial access in patients with acute myocardial infarction undergoing percutaneous coronary intervention. Objective: To compare the occurrence of adverse cardiovascular ischemic and hemorrhagic events in patients undergoing primary angioplasty according to the type of arterial access route. Methods: From August 2010 to December 2011, 588 patients undergoing primary percutaneous coronary intervention during acute ST-segment elevation myocardial infarction were assessed; they were recruited from 47 centers participating in the ACCEPT registry. Patients were grouped and compared according to the arterial access used for the procedure. Results: The mean age was 61.8 years; 75% were males and 24% had diabetes mellitus. There was no difference between groups as regards the procedure success rate, as well as regards the occurrence of death, reinfarction, or stroke at six months of follow-up. Severe bleeding was reported in 1.1% of the sample analyzed, with no statistical difference related to the access used. Conclusions: The femoral and radial accesses are equally safe and effective for the performance of primary percutaneous coronary intervention. The low rate of cardiovascular events and of hemorrhagic complications reflects the quality of the participating centers and the operators expertise with the use of both techniques. .

Fundamentos: O acesso radial promove menor risco de sangramento e complicações vasculares relacionadas ao sítio de punção quando comparado ao acesso femoral. Estudos recentes sugerem redução de mortalidade favorável ao primeiro em pacientes com infarto agudo do miocárdio submetidos à intervenção coronária percutânea. Objetivo: Comparar a ocorrência de eventos cardiovasculares adversos isquêmicos e hemorrágicos em pacientes submetidos à angioplastia primária conforme a via de acesso arterial. Métodos: No período de agosto de 2010 a dezembro de 2011, foram avaliados 588 pacientes que realizaram intervenção coronária percutânea primária na vigência de um infarto agudo do miocárdio com supradesnivelamento de ST, incluídos em 47 centros participantes do registro ACCEPT. Os pacientes foram agrupados e comparados de acordo com a via de acesso arterial utilizada para a efetivação do procedimento. Resultados: A média de idade foi de 61,8 anos, sendo 75% pertencentes ao sexo masculino e 24% portadores de diabetes melito. Não houve diferença entre os grupos na taxa de sucesso do procedimento, bem como na ocorrência de óbito, reinfarto ou acidente vascular encefálico aos seis meses de seguimento. Sangramento grave foi relatado em 1,1% da amostra analisada, sem diferença estatística conforme a via de acesso utilizada. Conclusões: As vias de acesso femoral e radial são igualmente seguras e eficazes para a realização de intervenção coronária percutânea primária. A baixa taxa de eventos cardiovasculares, bem como de complicações hemorrágicas, reflete a qualidade dos centros participantes e a experiência dos operadores com a utilização de ambas as técnicas. .

Prevalence, risk factors and outcomes associated with pulmonary hemorrhage in newborns / Prevalência, fatores de risco e prognóstico associados à hemorragia pulmonar em recém-nascidos

OBJECTIVES: to determine the prevalence of pulmonary hemorrhage in newborns and evaluate the associated risk factors and outcomes. METHODS: this was a retrospective case-control study involving 67 newborns who met the criteria for pulmonary hemorrhage. A control was selected for each case: the next-born child of the same gender, similar weight (± 200 g) and gestational age (± 1 week), with no previous pulmona ry hemorrhage and no malformation diagnosis. Factors previous to pulmonary hemorrhage onset, as well as aspects associated to the condition, were assessed. RESULTS: the prevalence was 6.7 for 1,000 live births, and the rates observed were: 8% among newborns < 1,500 g, and 11% among newborns < 1,000 g. Intubation in the delivery room (OR = 7.16), SNAPPE II (OR = 2.97), surfactant use (OR = 3.7), and blood components used previously to pulmonary hemorrhage onset (OR = 5.91) were associated with pulmonary hemorrhage. In the multivariate logistic regression model, only intubation in delivery room and previous use of blood components maintained the association. Children with pulmonary hemorrhage had higher mortality (OR = 7.24). Among the survivors, the length of stay (p < 0.01) and mechanical ventilation time were longer (OR = 25.6), and oxygen use at 36 weeks of corrected age was higher (OR = 7.67). CONCLUSIONS: pulmonary hemorrhage is more prevalent in premature newborns, and is associated with intubation in the delivery room and previous use of blood components, leading to high mortality and worse clinical evolution. .

OBJETIVOS : determinar a prevalência de hemorragia pulmonar entre os recém-nascidos internados no serviço e avaliar os fatores de risco e prognóstico associados. MÉTODOS: estudo retrospectivo caso-controle com 67 recém-nascidos que preencheram os critérios pré-estabelecidos de hemorragia pulmonar. Para cada caso, foi selecionado um controle: a próxima criança nascida do mesmo sexo, com semelhantes peso (± 200 g), idade gestacional (± 1 semana) e sem hemorragia pulmonar ou malformações. Foram estudados fatores prévios à ocorrência da hemorragia pulmonar e aspectos decorrentes do evento. RESULTADOS: a prevalência foi de 6,7 a cada 1.000 nascidos vivos, sendo de 8% entre os recém-nascidos menores que 1.500 g e de 11% entre os recém-nascidos menores que 1.000 g. A necessidade de intubação (IOT) em sala de parto (OR = 7,16), uso de hemoderivados previamente à ocorrência de hemorragia pulmonar (OR = 5,91), uso de surfactante (OR = 3,7) e SNAPPEII > 30 (OR = 2,97) foram associados à hemorragia pulmonar. No modelo de regressão logística multivariado, a necessidade de IOT (OR = 5,12) e uso de hemoderivados (OR = 4,2) mantiveram essa associação. As crianças com hemorragia pulmonar apresentaram maior mortalidade (OR = 7,24), entre as sobreviventes, maior tempo de internação (p < 0,01), mais uso de oxigênio com 36 semanas (OR = 7,67) e maior duração da ventilação mecânica (OR = 35,6). CONCLUSÃO: a hemorragia pulmonar é uma doença de maior prevalência em recém-nascidos pré-termos, e está associada à intubação em sala de parto e ao uso prévio de hemoderivados, acarretando maior mortalidade e pior evolução clínica das crianças. .

O escore de risco de sangramento como preditor de mortalidade em pacientes com síndromes coronarianas agudas / The bleeding risk score as a mortality predictor in patients with acute coronary syndrome

FUNDAMENTO: A ocorrência de sangramento aumenta a mortalidade intra-hospitalar em pacientes com síndromes coronarianas agudas (SCAs), e há uma boa correlação entre os escores de risco de sangramento e a incidência de eventos hemorrágicos. No entanto, o papel dos escores de risco de sangramento como fatores preditivos de mortalidade é pouco estudado. OBJETIVO: Analisar o papel do escore de risco de sangramento como fator preditivo de mortalidade intra-hospitalar numa coorte de pacientes com SCA tratados num centro terciário de cardiologia. MÉTODOS: Dos 1.655 pacientes com SCA (547 com SCA com supra de ST e 1.118 com SCA sem supra de ST), calculou-se o escore de risco de sangramento ACUITY/HORIZONS prospectivamente em 249 pacientes e retrospectivamente nos demais 1.416. Informações sobre mortalidade e complicações hemorrágicas também foram obtidas. RESULTADOS: A idade média da população estudada foi 64,3 ± 12,6 anos e o escore de risco de sangramento médio foi 18 ± 7,7. A correlação entre sangramento e mortalidade foi altamente significativa (p < 0,001; OR = 5,29), assim como a correlação entre escore de sangramento e hemorragia intra-hospitalar (p < 0,001; OR = 1,058), e entre escore de sangramento e mortalidade intra-hospitalar (OR ajustado = 1,121, p < 0,001, área sob a curva ROC 0,753; p < 0,001). O OR ajustado e a área sob a curva ROC para a população com SCA com supra de ST foram 1,046 (p = 0,046) e 0,686 ± 0,040 (p < 0,001), respectivamente, e para SCA sem supra de ST foram 1,150 (p < 0,001) e 0,769 ± 0,036 (p < 0,001), respectivamente. CONCLUSÃO: O escore de risco de sangramento é um fator preditivo muito útil e altamente confiável para mortalidade intra-hospitalar em uma grande variedade de pacientes com SCAs, especialmente aqueles com angina instável ou infarto agudo do miocárdio sem supra de ST.

BACKGROUND: It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied. OBJECTIVE: The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center. METHODS: Out of 1655 patients with ACS (547 with ST-elevation ACS and 1118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1416. Mortality information and hemorrhagic complications were also obtained. RESULTS: Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001). CONCLUSIONS: Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.

Análise de causalidade da relação entre sangramento e letalidade de Síndromes Coronarianas Agudas / Causality analysis of the relationship between bleeding and lethality in Acute Coronary Syndromes

FUNDAMENTO: Eventos hemorrágicos em Síndromes Coronarianas Agudas (SCA) apresentam associação independente com óbito em registros multicêntricos internacionais. No entanto, essa associação não foi testada em nosso meio e a verdadeira relação causal entre sangramento e óbito não está plenamente demonstrada. OBJETIVO: Testar as hipóteses de que: (1) sangramento maior é preditor independente de óbito hospitalar em SCA; (2) a relação entre esses dois desfechos é causal. MÉTODOS: Incluídos pacientes com critérios pré-definidos de angina instável, infarto sem supradesnivelamento do ST ou infarto com supradesnivelamento do ST. Sangramento maior durante o internamento foi definido de acordo com os tipos 3 ou 5 da Classificação Universal de Sangramento. Regressão logística e análise da sequência de eventos foram utilizadas para avaliar a associação entre sangramento e óbito. RESULTADOS: Dentre 455 pacientes estudados, 29 desenvolveram sangramento maior (6,4%; 95%IC = 4,3-9,0%). Esses indivíduos apresentaram mortalidade hospitalar de 21%, comparados a 5,6% nos pacientes sem sangramento (RR = 4,0; 95%IC = 1,8-9,1; P = 0,001). Após ajuste para escore de propensão, sangramento maior permaneceu preditor de óbito hospitalar (OR = 3,34; 95%IC = 1,2-9,5; P = 0,02). Houve 6 óbitos dentre 29 pacientes que sangraram. No entanto, análise detalhada da sequência de eventos demonstrou relação causal em apenas um caso. CONCLUSÃO: (1) Sangramento maior é preditor independente de óbito hospitalar em SCA; (2) O papel do sangramento como marcador de risco predomina sobre seu papel de fator de risco para óbito. Essa conclusão deve ser vista como geradora de hipótese a ser confirmada por estudos de maior tamanho amostral. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

BACKGROUND: Hemorrhagic events in Acute Coronary Syndromes (ACS) have been independently associated with death in international multicenter registries. However, that association has not been tested in Brazil and the true causal relationship between bleeding and death has not been completely shown. OBJECTIVE: To test the following hypotheses: (1) major bleeding is an independent predictor of in-hospital death in ACS; (2) the relationship between those two endpoints is causal. METHODS: This study included patients meeting predefined criteria of unstable angina, non-ST-segment elevation myocardial infarction or ST-segment elevation myocardial infarction. Major bleeding during hospitalization was defined according to the Bleeding Academic Research Consortium (types 3 or 5). Logistic regression and analysis of the sequence of events were used to assess the association between bleeding and death. RESULTS: Of the 455 patients studied, 29 experienced major bleeding (6.4%; 95% CI = 4.3-9.0%). They had in-hospital mortality of 21%, as compared with 5.6% of those not experiencing bleeding (RR = 4.0; 95% CI = 1.8-9.1; P = 0.001). After adjusting for the propensity score, major bleeding remained as a predictor of in-hospital death (OR = 3.34; 95% CI = 1.2-9.5; P = 0.02). Of the 29 patients who experienced bleeding, six died. However, the detailed analysis of the sequence of events showed causal relationship only in one case. CONCLUSION: (1) Major bleeding is an independent predictor of in-hospital death in ACS; (2) the role of bleeding as a risk marker overcomes that as a risk factor for death. This conclusion should be seen as a hypothesis generator to be confirmed by larger-sample studies. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

Impacto da utilização do acesso radial na ocorrência de sangramento grave entre idosos submetidos a intervenção coronária percutânea / Impact of the tranradial approach in the occurrence of major bleeding in elderly patients undergoing percutaneous coronary intervention

Introdução: A ocorrência de sangramento grave após intervenção coronária percutânea (ICP) sabidamente associa-se a maior morbidade e mortalidade, sendo a idade avançada um de seus principais preditores. O objetivo da presente análise foi avaliar o impacto da utilização do acesso radial na incidência de complicações hemorrágicas entre idosos submetidos a ICP. Métodos: Registro consecutivo, controlado, envolvendo pacientes com idade > 60 anos submetidos a ICP pelo acesso radial. Avaliou-se o sucesso angiográfico do procedimento, a falência da técnica, e a taxa de eventos adversos isquêmicos e de sangramento grave. Resultados: Entre maio de 2008 e dezembro de 2010, 707 pacientes idosos foram submetidos a ICP, dos quais 635 (89,8%) por meio de acesso radial. Amédia de idade foi de 69,9 ± 7,2 anos, 11,5% tinham idade> 80 anos, 39,7% eram do sexo feminino e 30,9%, portadores de diabetes melito. Síndrome isquêmica aguda respondeu por 72% das indicações clínicas. A taxa de sucesso angiográfico foi de 96,8%, sendo necessária a troca da via de acesso em 2,8% dos casos. A mortalidade hospitalar situou-se em 2,4%, infarto agudo do miocárdio em 0,9%, acidente vascular encefálico em 0,3% e trombose do stent em 0,9%. Hematomas foram reportados em 1,6% dos procedimentos, sendo de 0,8% a taxa de sangramento grave. Conclusões: Entre pacientes idosos submetidos a ICP, representativos da prática contemporânea e de elevado risco para sangramento, o uso do acesso radial associou-se a baixa incidência de sangramento grave.

Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients

OBJECTIVE: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS: Consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients.

[Pancreatic pseudocysts complicated by hemorrhage and infection]

The occurrence of bleeding complications secondary to the development of pancreatic pseudocysts is rare but associated with high mortality. To report a case of pancreatic pseudocyst complicated by hemorrhage and infection A 62 years old patient with history of severe acute pancreatitis two months ago consulted for abdominal pain associate with fever and internal bleeding. CT scan showed a heterogeneous PK complicated by hematoma of the ACE and hemoperitoneum. The emergency surgical treatment showed a PK superinfected with erosion of the splenic artery. It was directed by a left splenopancreatectomy Therapeutic management of hemorrhagic complications of pancreatic pseudo cysts is surgery despite the contribution of art‚rio-embolisation

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial / Efectos del ácido tranexámico sobre la mortalidad, eventos oclusivos vasculares y transfusiones de sangre en pacientes con traumatismos con hemorragias significativas (CRASH-2): estudio aleatorio, controlado con placebo

BACKGROUND: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. METHODS: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.gov NCT00375258, and South African Clinical Trial Register DOH-27-0607-1919. RESULTS: 10 096patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14-5%] tranexamic acid group vs 1613 [16-0%] placebo group; relative risk 0-91, 95% CI 0-85-0-97; p = 0-0035). The risk of death due to bleeding was significantly reduced (489 [4-9%] vs 574 [5-7%]; relative risk 0-85, 95% CI 0-76-0-96; p = 0-0077). CONCLUSION: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis ofthese results, tranexamic acid should be considered for use in bleeding trauma patients.

ANTECEDENTES: El ácido tranexámico puede reducir las hemorragias en pacientes que serán sometidos a cirugía electiva. Evaluamos los efectos de la administración anticipada de un tratamiento de corta duración con ácido tranexámico sobre la mortalidad, los eventos oclusivos vasculares y la administración de transfusiones de sangre en pacientes con traumatismos. MÉTODOS: Este estudio controlado aleatorio se realizó en 274 hospitales distribuidos en 40países. Se asignó en forma aleatoria un total de 20.211 pacientes adultos con traumatismos, con riesgos o no de tener una hemorragia significativa dentro de las 8 horas de la lesión al tratamiento con ácido tranexámico (dosis de carga 1 g durante 10 min. y luego infusión de 1 gen 8 horas) o placebo en forma similar. La distribución aleatoria se equilibró en cada centro, con una secuencia de asignaciones basada en un tamaño de bloque de ocho, generado por un generador de números aleatorios por computadora. Tanto los participantes como el personal del estudio (investigadores del centro y personal del centro que coordinaba el estudio) desconocían la asignación de los tratamientos. El principal resultado fue la mortalidad en el hospital dentro de las 4 semanas de ocurrida la lesión, que se describió con las siguientes categorías: hemorragia, oclusión vascular (infarto de miocardio, accidente cerebrovascular y embolia pulmonar), falla multiorgánica, lesión en la cabeza y otros. Todos los análisis se realizaron con intención de tratar. Este estudio está registrado como ISRCTN86750102, Clinicaltrials.gov NCT00375258, y Registro de Estudios Clínicos Sudafricano DOH-27-0607-1919. RESULTADOS: Se asignaron 10 096 pacientes al tratamiento con ácido tranexámico y 10 115 al tratamiento con placebo, de los cuales se analizaron 10 060 y 10 067, respectivamente. La mortalidad por cualquier causa se redujo significativamente con el tratamiento con ácido tranexámico (1463 [14.5%] del grupo que recibió ácido tranexámico comparados con 1613 [16.0%] del grupo que recibió placebo; riesgo relativo 0.91, 95% CI 0.85-0.97; p = 0.0035). El riesgo de muerte debido a hemorragias se redujo significativamente (489 comparado con 574; riesgo relativo 0.85, 95% CI 0.76-0.96; p = 0.0077). CONCLUSIÓN: En este estudio el ácido tranexámico redujo con seguridad el riesgo de muerte en pacientes con traumatismos hemorrágicos. En base a estos resultados, debe considerarse la utilidad del ácido tranexámico en pacientes con traumatismos hemorrágicos.

Educación medica continua: enfermedad hemorrágica del recien nacido por deficiencia de vitamina K / Continuing medical education: hemorrhagic disease of newborn vitamin K deficiency

La enfermedad hemorrágica del recien nacido por deficiencia de vitamina K se debe a una acentuada disminución de los factores de coagulación II, VII, IX y X, proteinas hepáticas llamadas factores del complejo protrombínico que son dependientes de la vitamina K ya que son activados por esta substancia.

Mortalidad en prematuros tratados con surfactante exógeno / Mortality in premature infants treated with exogenous surfactant

Objective: Characterize mortality and associated factors in Chilean prematures born < 32 weeks of gestational age (GA) and treated with exogenous surfactant. Method: Cohort of newborns (n = 2 868) registered between 1998-2005 in the database of the Surfactant National Program. The association of gestational and neonatal variables with mortality was estimated through survival analysis and logistic regression. Results: Global mortality was 35 percent, varying by GA from 86.7 percent (< 25 weeks) to 12.6 percent (32 weeks). There was a clear decrease of mortality during the study period, along with a fall in the gestational age and birth weight (BW) of the patients who died (1 021 g +/- 295 to 854 g +/- 258) and GA (27.7 +/- 2.1 to 26.5 +/- 23) during this period. Pulmonary hemorrhage (PH) was the most important factor associated to mortality, so we decided to stratify the analysis by this condition. In children with PH, the mortality estimated risk lower as the GA increased (OR= 0.73; CI95 0.57-0.93) and every 100 g of additional BW (OR= 0.74; CI95 0.63-0.88). Children not affected by PH also had their OR diminished with major GA (OR= 0.82; CI95 0.76-0.90) and more BW (OR= 0.84; CI95 0.79 - 0.89). In addition, the OR decreased with better Apgar 5 min score (OR= 0.80; CI95 0.75-0.85), use of prenatal corticoids (OR= 0.71; CI95 0.56-0.90) and was higher in boys (OR= 1.36; CI95 1.08-1.71). Conclusions: Mortality in premature newborns decreased 15 percent during this period. Inmaturity and extreme low birth weight factors constitute a challenge to improve survival and avoid further complications like PH.

Objetivo: Caracterizar la mortalidad y factores asociados en prematuros chilenos < 32 semanas de edad gestacional (EG) receptores de surfactante exógeno. Pacientes y Métodos: Cohorte de neonatos 1998-2005 (n = 2 868) de la base de datos del Programa Nacional de Surfactante. Se estimó la mortalidad y su relación con variables maternas, del embarazo y neonatales mediante análisis de sobrevida y regresión logística. Resultados: La mortalidad global fue 35 por ciento, variando por EG entre 86,7 por ciento (< 25 semanas) y 12,6 por ciento (32 semanas). La mortalidad descendió en el período, reduciéndose también el peso de nacimiento (PN) de los fallecidos (1 02 lg +/- 295 a 854 g +/- 258) y su EG (27,7 +/- 2,1 a 26,5 +/- 2,3). La hemorragia pulmonar (HP) fue el factor más importante asociado a mortalidad, por lo que se estratificó el análisis por esa condición. En niños con HP, cada semana adicional de EG disminuye el riesgo de morir (OR: 0,73; IC95 0,57-0,93), así como por cada 100 g de peso adicional (OR: 0,74; IC95 0,63-0,88). Sin HP, el riesgo disminuye con mayor EG (OR: 0,82; IC95 0,76-0,90), mayor PN (OR: 0,84; IC95 0,79-0,89), mejor puntuación Apgar 5 minutos (OR: 0,80; IC95 0,75-0,85) y uso de corticoide prenatal (OR: 0,71; IC95 0,56-0,90), siendo significativamente mayor en varones (OR: 1,36; IC(95)1,08-1,71). Conclusiones: En el período, la mortalidad en prematuros disminuyó en 15 por ciento. La inmadurez y extremo bajo peso de niños actualmente viables, plantean importantes desafíos para mejorar su sobrevida y evitar complicaciones, entre ellas, la HP.

Maternal mortality in Bahrain 1987-2004: an audit of causes of avoidable death

The aim of this report was to establish the national maternal mortality rate in Bahrain over the period 1987-2004, to identify preventable factors in maternal deaths and to make recommendations for safe motherhood. There were 60 maternal deaths out of 243 232 deliveries giving an average maternal mortality rate of 24.7 per 100 000 total births. The main causes of death were sickle-cell disease [25.0%], hypertension [18.3%], embolism [13.3%], haemorrhage [13.3%], heart disease [11.7%], infection [8.3%] and other [10.0%]. In an audit of care, 17 [28.3%] out of 60 deaths were judged to be avoidable, nearly half of which were due to a shortage of intensive care beds. We recommend that a confidential enquiry of maternal deaths be conducted at the national level every 3 to 5 years