Morbi-mortalidad de la enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro" / Morbi-mortality of venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital

Introducción: La enfermedad tromboembólica venosa es un proceso grave y mortal, considerado un problema de salud a escala mundial. Objetivo: Caracterizar la morbi-mortalidad por enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro". Métodos: Se realizó un estudio descriptivo retrospectivo de corte transversal a una muestra de 290 casos atendidos en el Hospital Universitario "Arnaldo Milián Castro" de Villa Clara, entre febrero de 2014 y febrero de 2016. Las variables fueron: edad, sexo, factores de riesgo, forma de presentación de la enfermedad y tipo de diagnóstico. Resultados: Se observó un predominio del sexo femenino y de los pacientes mayores de 70 años, independientemente del sexo y la inmovilidad como factor de riesgo. La trombosis venosa profunda del sector íleo-femoral fue la forma de presentación más común. El diagnóstico clínico primó, aunque el tromboembolismo pulmonar, como la complicación principal, se diagnosticó por necropsia. La mayor cantidad de trombosis venosa profunda se registró en el Servicio de Angiología, mientras que las muertes por embolia pulmonar predominaron en el Servicio de Terapia Intensiva. El tratamiento médico más utilizado fue la heparina sódica más warfarina; el profiláctico se realizó solo en el 24,7 por ciento de los casos. La heparina sódica se utilizó más en los servicios de Terapia Intensiva. Conclusiones: La enfermedad tromboembólica venosa fue la principal causa de muerte prevenible en el hospital, lo que sugiere que la profilaxis antitrombótica debe resultar una práctica esencial en los pacientes hospitalizados(AU)

Introduction: Venous thromboembolic disease is a serious and fatal process considered a health problem on a global scale. Objective: Characterize morbidity and mortality due to venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital. Methods: A retrospective descriptive cross-sectional study was conducted on a sample of 290 cases treated at "Arnaldo Milián Castro" University Hospital in Villa Clara between February 2014 and February 2016. The variables were: age, sex, risk factors, form of presentation of the disease and type of diagnosis. Results: A predominance of the female sex and patients over 70 years of age was observed, regardless of sex and immobility as risk factors. Deep vein thrombosis of the ileus-femoral sector was the most common form of presentation. Clinical diagnosis prevailed, although pulmonary thromboembolism, as the main complication, was diagnosed by necropsy. The highest amount of deep vein thrombosis was recorded in the Angiology Service, while deaths from pulmonary embolism predominated in the Intensive Care Service. The most commonly used medical treatment was sodium heparin plus warfarin; prophylaxis was performed only in 24.7 percent of cases. Sodium heparin was more used in Intensive Care services. Conclusions: Venous thromboembolic disease was the leading cause of preventable death in the hospital, suggesting that antithrombotic prophylaxis should be an essential practice in hospitalized patients.

Temporal trends in vena cava filter implantation in public health system inpatients: an 11-year analysis of the largest city in Brazil / Tendência temporal do implante de filtro de veia cava em pacientes internados no SUS em São Paulo: análise de 11 anos da maior cidade do Brasil

Abstract Background Vena cava filter implantation is considered a simple procedure, which can lead to overuse and over-indication. It is nevertheless associated with short and long-term complications. Objectives The goals of this study were to evaluate rates of vena cava filter implantation conducted by Brazil's Unified Public Health System, analyzing in-hospital mortality and migration of patients from other cities seeking medical attention in São Paulo. Methods This study analyzed all vena cava filter procedures conducted from 2008 to 2018 in the city of São Paulo and registered on the public database using a big data system to conduct web scraping of publicly available databases. Results A total of 1324 vena cava filter implantations were analyzed. 60.5% of the patients were female; 61.7% were under 65 years old; 34.07% had registered addresses in other cities or states; and there was a 7.4% in-hospital mortality rate. Conclusions We observed an increase in the rates of use of vena cava filters up to 2010 and a decrease in rates from that year onwards, which coincides with the year that the Food and Drug Administration published a recommendation to better evaluate vena cava filter indications.

Resumo Contexto O implante de filtro de veia cava é considerado um procedimento de baixa complexidade, o que pode resultar em indicação excessiva. No entanto, não é isento de complicações a curto e longo prazo. Objetivos Avaliar as taxas de implantes de filtro de veia cava realizados pelo Sistema Único de Saúde e a origem geográfica e mortalidade intra-hospitalar dos pacientes. Métodos Foi conduzida uma análise em um banco de dados públicos referente às taxas de implantes de filtro de veia cava realizados de 2008 a 2018 na cidade de São Paulo, utilizando o sistema de big data. Resultados Foram analisados 1.324 implantes de filtro de veia cava financiados pelo Sistema Único de Saúde. Identificou-se tendência de aumento da taxa de implantação até 2010 e de redução dos números após esse período. Do total de pacientes, 60,5% eram do sexo feminino; 61,75% tinham menos de 65 anos; e 34,07% possuíam endereço oficial em outra cidade ou estado. A taxa de mortalidade intra-hospitalar foi de 7,4%. Conclusões Observamos aumento das taxas de implante de filtro de veia cava até 2010 e redução das taxas após esse período, o que coincide com o ano em que a organização norte-americana Food and Drug Administration publicou uma recomendação para melhor avaliar as indicações de filtros.

Aneurismas por Estreptococo Pneumoniae / Aneurysms by Streptococcal Pneumoniae

El Estreptococo Pneumoniae es un microorganismo patógeno capaz de causar en humanos diversas infecciones y procesos invasivos severos, siempre graves y potencialmente letales. El objetivo de este trabajo fue mostrar la infrecuente presencia del Estreptococo Pneumoniae en la aparición de los aneurismas micóticos aórticos y de arterias periféricas, una asociación muy particular que coloca al cirujano vascular ante una especial conducta terapéutica encaminada a erradicar la infección, evitar la ruptura y sustituir la arteria, para mantener la continuidad de la luz del vaso y prevenir situaciones graves de isquemia(AU)

Streptococcal Pneumoniae is a pathogenic microorganism capable of causing in humans various infections and severe, always serious and potentially lethal invasive processes. The objective of this work was to show the rare presence of Streptococcal Pneumoniae in the onset of aortic mycotic aneurysms and peripheral arteries, a very particular association that places the vascular surgeon in an special therapeutic behavior aimed at eradicating the infection, preventing ruptures and replacing the artery, to maintain the continuity of vessel's light and prevent serious ischemia's situations(AU)

Morbimortalidad de las reintervenciones en la cirugía abdominal urgente y electiva / Morbidity and Mortality for Re-interventions in Urgent and Elective Abdominal Surgery

Introducción: Las reintervenciones en la cirugía abdominal, son causa de una alta mortalidad en los servicios de cirugía general. Objetivo: Caracterizar morbimortalidad de las reintervenciones de la cirugía abdominal urgente y electiva en el servicio de cirugía general del Hospital Universitario "Manuel Ascunce Domenech". Métodos: Se realizó un estudio observacional descriptivo transversal, de los pacientes que requirieron de reintervención quirúrgica abdominal. El universo estuvo conformado por 236 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: Predominó el grupo de edades de 40-49 años, así como el sexo masculino, con un 25 por ciento y 64,8 por ciento, respectivamente. En cuanto al tiempo en que se realizó la reintervención 72,5 por ciento se realizó luego de las 48 horas. El 88,6 por ciento de los pacientes resolvió la causa que lo originó en la primera reintervención. Las causas más frecuentes fueron la peritonitis generalizada seguida de los abscesos intrabdominales con un 19,5 por ciento y 17,4 por ciento respectivamente. La mortalidad fue de 30,1 por ciento y el tromboembolismo pulmonar la causa directa de muerte en 12,3 por ciento de los casos. Conclusiones: Casi la totalidad de los casos fueron reintervenidos luego de las 48 horas y las dos terceras partes resolvieron en la primera intervención. La peritonitis generalizada y los abscesos intrabdominales fueron la causa de la reintervención en un número importante(AU)

Introduction: Abdominal surgery re-interventions cause high mortality in general surgery services. Objective: To characterize morbidity and mortality of urgent and elective abdominal surgery re-interventions in the general surgery service of Manuel Ascunce Domenech University Hospital. Methods: A cross-sectional, descriptive, observational study was carried out with patients who required abdominal surgical re-intervention. The universe consisted of 236 patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: There was a predominance of the age group 40-49 years and the male sex, accounting for 25 percent and 64.8 percent, respectively. Regarding time of performance of re-intervention, 72.5 percent was carried out after 48 hours. 88.6 percent of the patients had, in the first re-intervention, a solution for the cause that originated it. The most frequent causes were generalized peritonitis, followed by intraabdominal abscesses, accounting for 19.5 percent and 17.4 percent, respectively. Mortality was 30.1 percent and pulmonary embolism was the direct cause of death in 12.3 percent of cases. Conclusions: Almost all the cases were re-intervened after 48 hours and two thirds had a solution the first re-intervention. Generalized peritonitis and intraabdominal abscesses were the cause of re-intervention, in a significant number(AU)

Tromboembolismo de pulmón: Sospecha clínica y correlación anatomopatológica / Pulmonary embolism. Clinical suspicion and anatomopathological correlation

Las discrepancias entre la sospecha clínica y los hallazgos patológicos en el tromboembolismo pulmonar (TEP) son frecuentes. El objetivo de este estudio fue analizar la prevalencia de TEP en una serie de necropsias de fallecidos en un hospital general de agudos entre 1998 y 2017, su relación con la sospecha clínica y su importancia como causa de muerte. Es un estudio retrospectivo y observacional de 350 autopsias realizadas en el Servicio de Patología; analiza características demográficas, principales diagnósticos clínicos informados en la solicitud de autopsia (sospecha clínica de muerte), incidencia anatomopatológica de TEP, diagnósticos primarios de autopsia relacionados con la muerte y concordancia entre sospecha clínica y diagnósticos de autopsia. En solo el 8% de las autopsias (n = 28), el TEP fue el diagnóstico clínico informado. En las autopsias, se encontró TEP en 127 casos (36.3%). Afectó arterias pulmonares grandes en 33 casos (25.9%), vasos medianos en 75 (59.1%) y vasos pequeños en 19 casos. El TEP se consideró el principal contribuyente o la causa principal de muerte en un 30.9% (n = 108) de los casos. Sin embargo, solo en el 15.7% de los casos confirmados había una sospecha clínica previa de TEP. Esta serie muestra que el TEP es un hallazgo de alta prevalencia y una causa importante de muerte en autopsias realizadas en un hospital de agudos. La evidencia de la baja concordancia entre los diagnósticos anatomopatológicos y clínicos del TEP alerta sobre la importancia de la sospecha clínica para lograr un tratamiento temprano de la enfermedad.

Discrepancies between clinical suspicion and pathological findings in pulmonary embolism (PE) appear to be frequent. The aim of this study was to analyze the prevalence of PE in a necropsy series of patients who have died in an acute care hospital between 1998-2017, its relationship with previous clinical suspicion, and its importance as a cause of death. It is a retrospective observational study of 350 autopsies done at the Department of Pathology. We analyzed the demographic characteristics, main clinical diagnoses stated in the autopsy request form, incidence of PE diagnosed, main autopsy findings related with the cause of death, as well as the concordance between clinical suspicion and autopsy diagnosis. In only 8% of the cases (n = 28) the clinical diagnosis of autopsy request was PE. An autopsy diagnosis of PE was done in 127 cases (36.3%); in 33 cases (25.9%) affected large pulmonary vessels; medium caliber vessels were affected in 75 cases (59.1%), and in 19 cases small vessels. The PE was considered as a contributor or cause of death in 30.9% (n = 108). However, only 15.7% of the confirmed PE cases had previous clinical suspicion. This series of necropsies shows that PE is a high prevalence finding in autopsies at an acute care hospital, and an important cause of death in a 20 years period. The finding of a low concordance with clinical diagnosis should alert the medical community on the importance of clinical suspicion in order to achieve an early diagnosis and treatment of this disease.

Mean platelet volume as a prognostic factor for venous thromboembolic disease / Volumen plaquetario medio como factor pronóstico de la enfermedad tromboembólica venosa

ABSTRACT Background: Mean platelet volume (MPV) is a risk factor for cardiovascular and inflammatory diseases. Aim: To evaluate the association between high MPV and 90-day mortality after an episode of venous thromboembolism (VTE). Material and Methods: Retrospective cohort of 594 patients with a median age of 73 years (58% women) with a first episode VTE, included in an institutional Thromboembolic Disease registry between 2014 and 2015. MPV values were obtained from the automated blood cell count measured at the moment of VTE diagnosis. Volumes ≥ 11 fL were classified as high. All patients were followed for 90 days to assess survival. Results: The main comorbidities were cancer in 221 patients (37%), sepsis in 172 (29%) and coronary artery disease in 107 (18%). Median MPV was 8 fl (8-9), brain natriuretic peptide 2,000 pg/ml (1,025-3,900) and troponin 40 pg/ml (19.5-75). Overall mortality was 20% (121/594) during the 90 days of follow-up. Thirty three deaths occurred within 7 days and 43 within the first month. The loss of patients from follow-up was 5% (28/594) at 90 days. Mortality among patients with high MP was 36% (23/63). The crude mortality hazard ratio (HR) for high MPV was 2.2 (95% confidence intervals (CI) 1.4-3.5). When adjusted for sepsis, oncological disease, heart disease, kidney failure and surgery, the mortality HR of high MPV was 2.4 (CI95% 1.5-3.9) in the VTE group, 2.3 (CI95% 1.5-4.4) in the deep venous thrombosis group, and 2.9 (CI95% 1.6 −5.6) in the pulmonary embolism group. Conclusions: High MPV is an independent risk factor for mortality following an episode of VTE.

Antecedentes: El volumen plaquetario medio (VPM) es un factor de riesgo de complicaciones cardiovasculares y enfermedades inflamatorias. Objetivo: Evaluar la asociación entre VPM alto y la mortalidad a los 90 días después de un episodio de tromboembolismo venoso (ETV). Material y Métodos: Cohorte retrospectiva de 594 pacientes adultos con una edad media de 73 años (58% mujeres) con un primer episodio de ETV incluidos en un registro de enfermedad tromboembólica institucional entre 2014 y 2015. Se obtuvieron valores de VPM desde el hemograma tomado en el momento del diagnóstico de ETV y un volumen ≥ 11 fL fue clasificado como alto. Todos los pacientes fueron seguidos durante 90 días para determinar sobrevida. Resultados: Las comorbilidades fueron cáncer en 221 pacientes (37%), sepsis en 172 (29%) y enfermedad coronaria en 107 (18%). La mediana de VPM fue 8 fl (89), el péptido natriurético cerebral fue de 2.000 pg/ml (1.025-3.900) y la troponina fue de 40 pg/ml (19,5-75). La mortalidad global a 90 días fue 20% (121/594). Treinta y tres muertes ocurrieron dentro de los 7 días y 43 en el primer mes. La pérdida de seguimiento de pacientes fue de 5% (28/594) a los 90 días. La mortalidad en el grupo con VPM alto fue 36% (23/63). La razón de riesgo (HR) cruda de la mortalidad para un VPM alto fue de 2,2 (intervalos de confianza (IC) de 95% 1,4-3,5). Cuando se ajustó por sepsis, enfermedad oncológica, enfermedad cardíaca, insuficiencia renal y cirugía, la HR de muerte para un VPM alto fue de 2,4 (IC95% 1,5-3,9) en el grupo de ETV; 2,3 (IC95% 1,5-4,4) en el grupo de trombosis venosa profunda; y 2,9 (CI95% 1,6 −5,6) en el grupo de embolia pulmonar. Conclusiones: Un VPM alto es un factor de riesgo independiente de mortalidad después de un episodio de ETV.

Fibrinolíticos en tromboembolismo de pulmón: Nuevas alternativas para una indicación controvertida / Fibrinolytics in lung thromboembolism. New alternatives for a controversial prescription

El uso de fibrinolíticos en el tromboembolismo de pulmón (TEP) es un tema de debate que ha sufrido idas y venidas desde su primera descripción en la década del 60. Esta terapia que puede liberar rápidamente la obstrucción mecánica en la arteria pulmonar, tiene la limitante del alto riesgo hemorrágico. Justamente por la incidencia prohibitiva de sangrado mayor y cerebral, y por la falta de beneficio en la supervivencia, es que solo está indicado el uso de fibrinolíticos sistémicos en el reducido número de pacientes con TEP grave y descompensación hemodinámica. En el TEP de moderado riesgo, aun con sufrimiento del ventículo derecho (VD), no están indicados. En los últimos años ha surgido la alternativa de combinar bajas dosis de fibrinolíticos liberados localmente en la arteria pulmonar mediante un catéter que puede adjuntarse o no a ultrasonidos en el sitio de la trombosis. Esta forma de administrar los trombolíticos permite corregir la hipertensión pulmonar aguda y liberar el trombo prácticamente sin sangrados mayores o del SNC. Los estudios publicados son muy alentadores, pero la evidencia aún es muy escasa, se requiere un laboratorio de hemodinamia disponible en todo momento y no está exento de riesgos, con un costo considerable. Por el momento solo un reducido número de pacientes con TEP moderado y parámetros de mal pronóstico parece tener indicación para esta alternativa.

The use of fibrinolytics in lung thromboembolism (PTE) is a subject under debate since its first description in the 1960s. This therapy, which can rapidly resolve the mechanical obstruction in the pulmonary artery, has the limiting of a high hemorrhagic risk. Precisely because of the prohibitive incidence of major and cerebral bleeding and the lack of benefit in survival, the use of systemic thrombolytics is only indicated in the small number of patients with severe PE and hemodynamic instability. In moderate-risk PE, even with right ventricular (RV) dysfunction, they are not indicated. In recent years, an alternative has arisen, by combining low doses of fibrinolytics released locally into the pulmonary artery through a catheter that may, or may not, be attached to ultrasound at the site of thrombosis. This way of administering thrombolytics can correct acute pulmonary hypertension and eliminate the thrombus without major or CNS bleeds. Although the published studies are very encouraging, the evidence is still poor, a laboratory of hemodynamics is required at all times and this procedure is not free of risks, with a considerable cost. At the moment, only a small number of patients with moderate PE and poor prognosis seem to have an indication for this new alternative.

Reperfusion in acute pulmonary thromboembolism / Reperfusão no tromboembolismo pulmonar agudo

ABSTRACT Acute pulmonary thromboembolism (APTE) is a highly prevalent condition (104-183 cases per 100,000 person-years) and is potentially fatal. Approximately 20% of patients with APTE are hypotensive, being considered at high risk of death. In such patients, immediate lung reperfusion is necessary in order to reduce right ventricular afterload and to restore hemodynamic stability. To reduce pulmonary vascular resistance in APTE and, consequently, to improve right ventricular function, lung reperfusion strategies have been developed over time and widely studied in recent years. In this review, we focus on advances in the indication and use of systemic thrombolytic agents, as well as lung reperfusion via endovascular and classical surgical approaches, in APTE.

RESUMO O tromboembolismo pulmonar (TEP) agudo é uma condição altamente prevalente (104-183 por 100.000 pessoas-ano) e potencialmente fatal. Aproximadamente 20% dos pacientes com TEP agudo apresentam-se hipotensos, sendo considerados pacientes com alto risco de morte. Nesses casos, a necessidade de reperfusão pulmonar imediata é mandatória para reduzir a pós-carga do ventrículo direito e restaurar a condição hemodinâmica do paciente. Visando a redução da resistência vascular pulmonar no TEP agudo e, por consequência, a melhora na função ventricular direita, estratégias de reperfusão pulmonar foram desenvolvidas com passar do tempo e vêm sendo muito estudadas nos últimos anos. Avanços na indicação e no uso de trombolíticos sistêmicos, reperfusão pulmonar via abordagem endovascular ou abordagem cirúrgica clássica no TEP agudo são os focos desta revisão.

Prevalência de tromboembolismo pulmonar incidental em pacientes oncológicos: análise retrospectiva em grande centro / Prevalência de tromboembolismo pulmonar incidental em pacientes oncológicos: análise retrospectiva em grande centro

Contexto: Devido à maior aplicação de exames de imagem rotineiros, especialmente nos pacientes com neoplasia para controle da doença, vem aumentando o diagnóstico de tromboembolismo pulmonar (TEP) incidental, importante fator de morbimortalidade associado. Objetivo: Identificar os casos de TEP incidental em pacientes oncológicos submetidos a tomografia computadorizada (TC) de tórax, correlacionando aspectos clínicos e fatores de risco associados. Métodos: Estudo retrospectivo de todos os episódios de TEP ocorridos de janeiro de 2013 a junho de 2016, com seleção dos pacientes oncológicos e divisão deles em dois grupos: com suspeita clínica e sem suspeita clínica (incidentais) de embolia pulmonar. Resultados: Foram avaliados 468 pacientes com TEP no período citado. Destes, 23,1% eram oncológicos, entre os quais 44,4% apresentaram achado incidental de embolia pulmonar na TC de tórax. Não houve diferença estatística entre os grupos para sexo, idade e tabagismo. Quanto à procedência, 58,3% dos pacientes sem suspeita clínica eram de origem ambulatorial e 41,7% com suspeita de TEP vinham do pronto-socorro (p < 0,001). As neoplasias mais prevalentes foram de pulmão (17,6%), intestino (15,7%) e mama (13,0%). Aqueles com achado incidental apresentaram significativamente mais metástases, sem diferença entre os grupos para realização de quimioterapia, radioterapia ou cirurgia recente. Quanto aos sintomas apresentados, 41,9% daqueles sem suspeita clínica tinham queixas sugestivas de TEP quando realizaram o exame. Conclusão: TEP incidental é frequente em pacientes oncológicos, especialmente naqueles provenientes de seguimento ambulatorial e em estágios avançados da doença. Sintomas sugestivos de TEP estavam presentes em pacientes sem suspeita clínica ao realizarem a TC de tórax

Background: Increased use of routine imaging exams has led to higher rates of incidental diagnosis of pulmonary thromboembolism (PTE), especially for management of disease in cancer patients, among whom it is an important factor in associated morbidity and mortality. Objective: To identify cases of incidental PTE in cancer patients examined with computed tomography (CT) of the thorax, correlating clinical features and associated risk factors. Methods: This is a retrospective study of all episodes of PTE diagnosed between January 2013 and June 2016, selecting cases involving cancer patients and dividing them into two subsets: those with clinical suspicion and those without clinical suspicion of pulmonary embolism (incidental cases). Results: At total of 468 patients had PTE during the period investigated and 23.1% of them were cancer patients, 44.4% of whom exhibited pulmonary embolism as an incidental finding of a chest CT. There was no statistical difference between the two subsets in terms of sex, age, or smoking. In terms of patients' admission status, 58.3% of the patients without clinical suspicion were outpatients and 41.7% of those with suspicion of PTE were admitted via the emergency room (p < 0.001). The most common cancer sites were lung (17.6%), intestine (15.7%), and breast (13.0%). Patients whose PTE were diagnosed incidentally exhibited a significantly greater rate of metastases, while there were no differences between the groups in terms of chemotherapy, radiotherapy, or recent surgery. Analysis of symptoms revealed that 41.9% of patients without clinical suspicion had complaints suggestive of PTE when they underwent the CT examination. Conclusions: Incidental PTE is common among cancer patients, especially those in outpatients follow-up and in advanced stages of the disease. Patients without clinical suspicion also had symptoms suggestive of PTE when they presented for chest CT

Terapia fibrinolítica sistêmica no tromboembolismo pulmonar / Systemic fibrinolytic therapy in pulmonary thromboembolism

O tromboembolismo pulmonar permanece como um grande desafio terapêutico para os médicos especialistas, pois, apesar de todo investimento e desenvolvimento em seu diagnóstico, profilaxia e tratamento, essa condição continua sendo a principal causa de morte evitável em ambiente hospitalar. Ainda restam muitas dúvidas em relação a qual perfil de paciente vai se beneficiar de fato da terapia fibrinolítica sistêmica, sem ficar exposto a um grande risco de sangramento. A estratificação de risco e a avaliação do prognóstico do evento, através de escores clínicos de insuficiência ventricular direita, marcadores de dilatação e disfunção do ventrículo direito e avaliação da massa trombótica, associados ou de forma isolada, são ferramentas que podem auxiliar na identificação do paciente que irá se beneficiar dessa terapia. Os únicos consensos em relação à terapia fibrinolítica no tratamento do tromboembolismo pulmonar são: não deve ser indicada de forma rotineira; nenhum dos escores ou marcadores, isoladamente, devem justificar seu uso; e os pacientes com instabilidade hemodinâmica são os mais beneficiados. Além disto, deve-se avaliar cada caso em relação ao risco de sangramento, especialmente no sistema nervoso central

Pulmonary thromboembolism remains a major therapeutic challenge for specialists and, despite investment and the consequent developments in diagnosis, prophylaxis, and treatment, the condition is still the leading cause of avoidable deaths in hospital settings. There is still great uncertainty with relation to the profile of patients who will actually benefit from systemic fibrinolytic treatment, without being exposed to serious risk of bleeding. There are tools that can help to identify patients who will benefit, including risk stratification and estimation of the prognosis of the event, with clinical scores for right ventricular failure, markers of right ventricular dysfunction and dilatation, and thrombotic mass assessment, whether alone or in combination. The only points of consensus with relation to fibrinolytic therapy for treatment of pulmonary thromboembolism are as follows: it should not be routinely indicated, none of the scores or markers alone should be used to justify its use, and patients with hemodynamic instability are the most likely to benefit. Furthermore, each case should be evaluated for risk of bleeding, especially central nervous system bleeding

Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes

OBJECTIVES: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential.

Nuevas consideraciones en el tratamiento del tromboembolismo pulmonar: new considerations in its treatment / Pulmonary tromboembolismo: new considerations in its treatment

La enfermedad tromboembólica tiene altas cifras de morbilidad y mortalidad. Se presenta en un variado espectro de pacientes. Continúa siendo un diagnóstico importante en la atención de las urgencias médicas por lo que hemos decidido realizar esta revisión bibliográfica con el objetivo de actualizar los conocimientos cada vez más necesarios, sobre el diagnóstico y la conducta que se debe asumir en esos casos. Teniendo en cuenta que su diagnóstico por técnicas de imagen es cada vez más difícil, lo que evidencia el valor del método clínico en esta impactante enfermedad, así como su prevención. Sin olvidar que a pesar de estar estandarizada cada conducta, debe valorarse la individualidad del paciente(AU)

Thromboembolic disease has high morbidity and mortality. It comes in a wide spectrum of patients. It remains an important diagnosis in the care of medical emergencies so we decided to do this literature review in order to update the increasingly necessary knowledge about the diagnosis and behavior that must be undertaken in such cases. Given that its diagnostic by imaging is increasingly difficult, the clinical method is valuable in this shocking disease and its prevention. Not to mention that despite being standardized each patient's individuality must be evaluated(AU)

Alternative diagnoses based on CT angiography of the chest in patients with suspected pulmonary thromboembolism / Diagnósticos alternativos corroborados por angiotomografia computadorizada de tórax em pacientes com suspeita de tromboembolia pulmonar

Objective : To determine the prevalence of alternative diagnoses based on chest CT angiography (CTA) in patients with suspected pulmonary thromboembolism (PTE) who tested negative for PTE, as well as whether those alternative diagnoses had been considered prior to the CTA. Methods : This was a cross-sectional, retrospective study involving 191 adult patients undergoing CTA for suspected PTE between September of 2009 and May of 2012. Chest X-rays and CTAs were reviewed to determine whether the findings suggested an alternative diagnosis in the cases not diagnosed as PTE. Data on symptoms, risk factors, comorbidities, length of hospital stay, and mortality were collected. Results : On the basis of the CTA findings, PTE was diagnosed in 47 cases (24.6%). Among the 144 patients not diagnosed with PTE via CTA, the findings were abnormal in 120 (83.3%). Such findings were consistent with an alternative diagnosis that explained the symptoms in 75 patients (39.3%). Among those 75 cases, there were only 39 (20.4%) in which the same alterations had not been previously detected on chest X-rays. The most common alternative diagnosis, made solely on the basis of the CTA findings, was pneumonia (identified in 20 cases). Symptoms, risk factors, comorbidities, and the in-hospital mortality rate did not differ significantly between the patients with and without PTE. However, the median hospital stay was significantly longer in the patients with PTE than in those without (18.0 and 9.5 days, respectively; p = 0.001). Conclusions : Our results indicate that chest CTA is useful in cases of suspected PTE, because it can confirm the diagnosis and reveal findings consistent with an alternative diagnosis in a significant number of patients.

Objetivo : Determinar a prevalência de diagnósticos alternativos corroborados por angiotomografia computadorizada (angio-TC) de tórax em pacientes com suspeita de tromboembolia pulmonar (TEP) e com resultados negativos para TEP, assim como investigar se esses diagnósticos alternativos já haviam sido identificados antes dos resultados da angio-TC. Métodos : Estudo transversal, retrospectivo, com 191 pacientes adultos que realizaram angio-TC por suspeita de TEP no período entre setembro de 2009 e maio de 2012. As radiografias de tórax e as angio-TCs foram revisadas para determinar se os achados poderiam fornecer um diagnóstico alternativo nos casos não diagnosticados como TEP. Dados sobre sintomas, fatores de risco, comorbidades, tempo de internação e mortalidade foram coletados. Resultados : A angio-TC foi positiva para tromboembolia pulmonar em 47 casos (24,6%). Entre os 144 pacientes sem tromboembolia pulmonar, achados anormais foram observados em 120 (83,3%). Tais achados foram compatíveis com um diagnóstico alternativo que explicava os sintomas do paciente em 75 casos (39,3%). Desses 75 casos, os achados não haviam sido detectados previamente na radiografia de tórax em apenas 39 (20,4%) dos casos. O diagnóstico alternativo mais frequente, identificado somente por angio-TC, foi pneumonia (em 20 casos). Sintomas, fatores de risco, comorbidades e taxa de óbito intra-hospitalar não diferiram significativamente entre os pacientes com ou sem TEP. Entretanto, a mediana de tempo de internação foi significativamente maior nos pacientes com TEP do que naqueles sem TEP (18,0 e 9,5 dias, respectivamente; p = 0,001). Conclusões : Nossos resultados demonstram que a angio-TC de tórax é útil em casos com suspeita de TEP, pois pode confirmar o diagnóstico e evidenciar achados sugestivos de um diagnóstico alternativo em um significativo número de pacientes.

Pulmonary Embolism Mortality in Brazil from 1989 to 2010: Gender and Regional Disparities / Mortalidade por Embolia Pulmonar no Brasil entre 1989 e 2010: Disparidades Regionais e por Gênero

Abstract Background: A significant variation in pulmonary embolism (PE) mortality trends have been documented around the world. We investigated the trends in mortality rate from PE in Brazil over a period of 21 years and its regional and gender differences. Methods: Using a nationwide database of death certificate information we searched for all cases with PE as the underlying cause of death between 1989 and 2010. Population data were obtained from the Brazilian Institute of Geography and Statistics (IBGE). We calculated age-, gender- and region-specific mortality rates for each year, using the 2000 Brazilian population for direct standardization. Results: Over 21 years the age-standardized mortality rate (ASMR) fell 31% from 3.04/100,000 to 2.09/100,000. In every year between 1989 and 2010, the ASMR was higher in women than in men, but both showed a significant declining trend, from 3.10/100,000 to 2.36/100,000 and from 2.94/100,000 to 1.80/100,000, respectively. Although all country regions showed a decline in their ASMR, the largest fall in death rates was concentrated in the highest income regions of the South and Southeast Brazil. The North and Northeast regions, the lowest income areas, showed a less marked fall in death rates and no distinct change in the PE mortality rate in women. Conclusions: Our study showed a reduction in the PE mortality rate over two decades in Brazil. However, significant variation in this trend was observed amongst the five country regions and between genders, pointing to possible disparities in health care access and quality in these groups.

Resumo Fundamento: Uma significativa variação nas tendências de mortalidade por embolia pulmonar (EP) foi documentada em todo o mundo. Investigamos as tendências na taxa de mortalidade por EP no Brasil no período de 21 anos, assim como suas diferenças regionais e de gênero. Métodos: Utilizando uma base de dados nacionais de certificados de óbito, buscamos todos os casos de EP como causa básica de morte entre 1989 e 2010. Dados populacionais foram obtidos no Instituto Brasileiro de Geografia e Estatística. Calculamos as taxas de mortalidade específica por idade, gênero e região para cada ano, usando a população brasileira do ano 2000 para padronização direta. Resultados: Nos 21 anos, a taxa de mortalidade padronizada por idade (TMPI) caiu 31%, passando de 3,04/100.000 para 2,09/100.000. Em cada ano entre 1989 e 2010, a TMPI foi maior nas mulheres do que nos homens, tendo ambos mostrado uma significativa tendência decrescente, de 3,10/100.000 para 2,36/100.000 e de 2,94/100.000 para 1,80/100.000, respectivamente. Embora todas as regiões do país tenham apresentado um declínio em suas taxas de mortalidade padronizada por idade, as maiores quedas concentraram-se nas regiões de mais alta renda do Sul e Sudeste do Brasil. As regiões Norte e Nordeste, que têm as mais baixas rendas, apresentaram uma queda menos marcante nas taxas de mortalidade, sem qualquer alteração na taxa de mortalidade por EP nas mulheres. Conclusões: Nosso estudo mostrou uma redução na taxa de mortalidade por EP nas duas décadas no Brasil. Entretanto, houve uma significativa variação nessa tendência entre as cinco regiões do país e entre gêneros, indicando uma possível disparidade no acesso aos cuidados de saúde e sua qualidade nesses grupos.

Profilaxia da síndrome de embolia gordurosa: uma análise atual / Prophylaxis of fat embolism syndrome: a current analysis

INTRODUÇÃO: Analisar dados da internet relacionados a mortes por embolia gordurosa, inicio da doença, e outras informações podem determinar a realidade atual no Brasil relacionada à incidência da síndrome de embolia gordurosa e qualquer repercussão na mídia, e também revisar as metodologias de prevenção e quais são os melhores métodos disponíveis para tratar a doença. MÉTODOS: Uma pesquisa no google foi conduzida de Janeiro de 2000 a Janeiro de 2014 utilizando os descritores "cirurgia plástica" e "morte". Foram incluídos e revisados artigos contendo as palavras "embolia", "embolia gordurosa" e "complicações em (ou de) cirurgia plástica". RESULTADOS: Incluiu-se 235 matérias novas relevantes ao longo dos 14 anos. Houve 45 casos de óbito relacionados com cirurgia plástica que ofereceu poucos dados para individualização. Desses pacientes, 44 eram mulheres. As causas possíveis mencionadas foram embolia pulmonar (cinco casos), perfuração das vísceras (cinco casos), hipertermia maligna (três casos), anestesia (dois casos), choque anafilático (dois casos), embolia gordurosa (um caso confirmado), e "outros" (cinco casos). CONCLUSÃO: Diretrizes de prevenção para embolia gordurosa em cirurgia plástica são requeridas, porém, há também necessidade de mais estudos baseados em evidência para entender mais claramente quais são os melhores métodos.

INTRODUCTION: To analyze data from the internet on deaths from fat embolism, time of onset, and other information that could determine current reality in Brazil regarding fat embolism syndrome incidence and any ,media repercussions, and also to review methods of prevention and what are the best methods available to treat this disease. METHODS: A Google search was conducted from January 2000 to January 2014 using the keywords "plastic surgery" and "death." We included and reviewed articles containing the words "embolism", "fat embolism" and "complications in (or of) plastic surgery". RESULTS: We included 235 relevant news stories over the 14 included years. There were 45 cases of death related with plastic surgery that offered few data for individualization. Of these patients, 44 were women. Possible causes mentioned were pulmonary embolism (five cases), perforation of viscera (four cases), malignant hyperthermia (three cases), anesthesia (two cases), anaphylactic shock (two cases), fat embolism (one confirmed case), and "other" (five cases). CONCLUSION: Guidelines to prevent fat embolism in plastic surgery are needed, however, there is also the need of more evidence based studies to understand more clearly what methods are best.

Forensic Analysis of 33 Cases of Fatal Pulmonary Thromboembolism / 法医学杂志

OBJECTIVE@#To explore the related risk facts of pulmonary thromboembolism (PTE) and analyze the relation between PTE and the trauma or medical behavior by investigating the cases of PTE.@*METHODS@#Thirty-three cases were selected from Institute of Forensic Science (IFS) from 2000 to 2014.@*RESULTS@#In 33 cases, 16 decedents were male, 17 decedents were female; different degrees of dyspnea, chest tight- ness and syncope symptoms were the clinical manifestation of the deceased; the thrombus was mainly distributed in the left and right pulmonary arteries. The main source of embolism was the deep vein of lower limb and the left probability was higher. Trauma, limited position, operation and cardiovascular disease showed high-risk factors of PTE; D-Dimer test, hemolytic test and computer tomography pul- monary angiography were the diagnostic tools for PTE. In some cases, trauma and medical malpractice could be involved in the cause of death.@*CONCLUSION@#Non-typical clinical symptoms present in the most cases caused by PTE, and these cases always show many high-risk factors. The relation between PTE and injury or medical behavior should be considered carefully in the forensic pathological practice.

Lipoaspiração e embolia gordurosa: revisão de literatura / Liposuction and fat embolism: a literature review

A cirurgia de lipoaspiração é com alguma frequência relacionada a consequências dramáticas ou fatais, causando grande repercussão no meio médico e principalmente na mídia leiga. Esse fato não deve fazer com que o cirurgião plástico evite essa cirurgia, mas sim estimulá-lo a conhecer profundamente a fisiopatologia inerente ao procedimento, buscando meios embasados de realizá-lo da forma mais segura possível, reduzindo ao máximo os riscos de complicações, principalmente as mais graves. Esse artigo teve o objetivo de realizar uma revisão bibliográfica a respeito especificamente da embolia gordurosa causada pela lipoaspiração, relacionada inúmeras vezes a pós-operatórios dramáticos e fatais. Além disso, ressalta alguns cuidados preventivos para uma maior segurança com esse procedimento.

Liposuction surgery is often associated with severe or fatal consequences, causing great repercussions in the medical field, and especially in the lay media . This should not cause the plastic surgeon to avoid the procedure, but rather should promote deeper knowledge of the basic pathophysiology. All means to accomplish the surgery in the safest possible way should be utilized, to minimize the risk of complications, especially the most severe risks. This article reviews the literature on liposuction-induced fat embolism, which is often associated with severe complications in the postoperative period, and even fatal outcomes. In addition, this study highlights several preventive measures that can be adopted to ensure greater safety of this procedure.

Protocolo de prevenção de tromboembolismo venoso em cirurgia plástica: resultados em 2759 pacientes no Instituto Ivo Pitanguy / Venous thromboemboembolism prevention protocol in plastic surgery: results in 2759 patients at the Ivo Pitanguy Institute

Introdução: A embolia pulmonar é a causa de morte mais previsível em pacientes hospitalizados, sendo isso ainda mais prevalente em pacientes cirúrgicos. 200.000 novos casos ocorrem anualmente, com início súbito e geralmente levando à morte nas primeiras 2 horas. Prevenir é, portanto, mais efetivo que tratar a doença estabelecida. Esse estudo objetiva demonstrar a importância e segurança do protocolo de prevenção do tromboembolismo venoso. Métodos: Conduzimos um estudo retrospectivo no período de maio de 2009 a maio de 2011, quando 2759 pacientes foram submetidos à cirurgia plástica no Instituto Ivo Pitanguy. Todos os pacientes foram submetidos ao protocolo de prevenção e avaliados quanto aos fatores de risco para tromboembolismo venoso. A soma desses fatores gerou um escore que determinou a conduta profilática a ser adotada. Resultados: Houve três casos de tromboembolismo venoso (0,1%), sendo 1 de TEP e 2 de TVP. A quimioprofilaxia com enoxaparina administrada aos 3 pacientes de acordo com o protocolo de prevenção. Nossas taxas permaneceram abaixo das encontradas na literatura, com diferença estatisticamente significativa nos numero total de casos (p < 0,0001). Houve 34 casos de hematoma (1,2%), sendo 55,9% em pacientes submetidos à quimioprofilaxia e 44,1% em pacientes que usaram apenas o dispositivo de compressão pneumática intermitente apenas. As taxas totais de hematoma também permaneceram abaixo das encontradas na literatura, também com diferença estatisticamente significativa (p < 0,001). Conclusão: O protocolo de prevenção do tromboembolismo venoso do Instituto Ivo Pitanguy se provou seguro e importante na prevenção dos casos de TEV, com taxas de hematoma abaixo do descrito na literatura.

Introduction: Pulmonary embolism is the most predictable cause of death in hospitalized patients, even more in surgical patients. 200.000 new cases occur annually, with sudden onset and generally leading to death in the first 2 hours. Preventing is most effective than treating stablished disease. This study aims to show the importance and safety of the venous thromboembolism prevention protocol. Methods: We conducted a retrospective study in the period between May 2009 and May 2011 at The Ivo Pitanguy Institute, where 2759 patients underwent plastic surgery (aesthetic and reconstructive). All patients were assessed for predisposing and exposing risk factors for venous thromboembolism and the sum of those factors generated a score determining the prophylactic procedure to be adopted according to the protocol. Results: There were three cases of venous thromboembolism (0.1%): one case of pulmonary embolism and two cases of deep venous thrombosis. Chemoprophylaxis with heparin was administered in the three patients according to the venous thromboembolism prevention protocol. Our rates remained below those found in the literature, with a statistically significant difference in total cases (p < 0.0001). There were 34 cases of hematoma (1.2%): 55.9% in patients submitted to pharmacological prophylaxis with heparin and 44,1% in patients who used sequential compression devices only. The total rates of hematoma also remained below those found in the literature with a statistically significant difference (p < 0,001). Conclusion: The venous thromboembolism prevention protocol of the Ivo Pitanguy Institute proved to be important and safe, preventing the occurrence of venous thromboembolism cases with low rates of hematoma.