Exposiçäo aguda a derivados imidazolínicos em crianças / Acute exposure to imidazoline derivatives in children

OBJETIVOS: Estudar a exposiçäo aguda a derivados imidazolínicos em crianças com idade inferior a 15 anos, atendidas no período de janeiro de 1994 a dezembro de 1999. MÉTODOS: Neste estudo retrospectivo foram avaliadas 72 crianças com idades entre dois meses e 13 anos, mediana de dois anos (25 por cento a 75 por cento; um a três anos), expostas a nafazolina (n = 48), fenoxazolina (n = 18), oximetazolina (n = 5) e tetrizolina (n = 1); por via oral (n = 46), nasal (n = 24) ou desconhecida (n = 2). RESULTADOS: No total, 57 crianças desenvolveram manifestações clínicas: sonolência (n = 34), sudorese (n = 20), palidez (n = 17), hipotermia (n = 16), bradicardia (n = 13), extremidades frias (n = 9), agitaçäo (n = 7), taquicardia (n = 6), vômitos (n = 34), respiraçäo irregular e apnéia (n = 5), miose/midríase (n = 4), sendo a nafazolina (n = 47), a fenoxazolina (n = 5) e a oximetazolina (n = 4) os princípios ativos mais envolvidos. O início das manifestações clínicas foi rápido, iniciando-se, em 32/57 crianças, até duas horas após a exposiçäo. Somente medidas de suporte foram empregadas, com uma criança necessitando de ventilaçäo mecânica após exposiçäo à nafazolina. Na maioria dos pacientes, o quadro clínico remitiu até 24 horas após a exposiçäo (n = 39/57). Näo houve evoluçäo letal. Pacientes expostos à nafazolina (n = 47/48) apresentaram maior freqüência de manifestações clínicas de intoxicaçäo em comparaçäo com aqueles expostos à fenoxazolina (n = 5/18) (p < 0,001). Comparando-se a freqüência de pacientes que desenvolveram manifestações clínicas de acordo com a via de exposiçäo (oral, n = 34/46; nasal, n = 21/24), näo foi encontrada uma diferença estatisticamente significante (p = 0,31). CONCLUSÕES: Na maioria dos casos de exposiçäo a derivados imidazolínicos, principalmente à nafazolina e em crianças com menos de três anos de idade, ocorreu, independentemente da via (oral ou nasal), o aparecimento precoce de manifestações clínicas de intoxicaçäo, destacando-se as depressöes neurológica, cardiovascular e respiratória, que regrediram até 24 horas após a exposiçäo

Multiple organ failure in septic patient

Multiple organ failure (MOF) is the main cause of death in ICUs, especially affecting septic patients.It is strongly related to number of systems with failure, type of system involved, risk factors such as age, previous chronic diseases, delayed or inadequate resuscitation, persistent infection, immune supression, and others. The prognoses is worse for patients rather than in elective or emergency surgical patients. The objective of this article is to provide data from our university teaching hospital ICU related to the incidence of septic patients, the distribution of MOF, and distribution of failure among each of the organs. The mortality rate, relationhip between mortality and age, and mortality and types of organs affected were evaluated. The main bacterial causes of septis were also identified. A retrospective evaluation was done of 249 patients admitted to the ICU in a 4 month period during 1999. Fifty four patients had sepsis diagnosed by ACCS/SCCM criteria. There were 37 men and 17 women; 24 medical and 30 post-surgical patients (9 after elective surgery and 21 emergency patients). APACHE II score was calculated on admission and MOF, measured for the first five days, was diagnosed using Marshall and Meakins criteria. The statistical method used was non-parametric Mann-Whitney test, p<0.05 was considered significant. The incidence of sepis was recorded in 52/249 patients (22 percent). Thirty of these 54 patients (56 percent) died. Death occurred in 2 of 11 patients with one organ failure (18 percent), in 14/27 with 2 or 3 organ failures (52 percent), and 14/16 with 4 or more organ failures (88 percent). None of the three patients 15 to 20 years years old died, 17/32 (55 percent) patients age 21-60 years, and >61 years 13/19 (68 percent), died. There were 23 patients with positive bacterial culture. The most frequent bacteria found were: Pseudomonas aeruginosa (5), multiresistant Acinetobacter baumanii (3), Streptococcus epidermidis (3), Enterobacter aerogenes (3), Klebsiella pneumoniae (2) and multiresistant Staphylococcus aureus (2). The mean value ñ SD of APACHE II (mortality risk) for survivors was 21 ñ 18 and non-survivors 42 ñ 26 (p<0.001). We conclude that MOF due to septis in an ICU is frequent, with high mortality related to the number of failing organs, age and high APACHE II.

Monitorizaçäo hemodinâmica invasiva no pós-operatório de cirurgia cardíaca / Invasive hemodynamic monitoring in the postoperative period of cardiac surgery

Objective - To assess the hemodynamic profile of cardiac surgery patients with circulatory instability in the early postoperative period (POP). Methods - Over a two-year period, 306 patients underwent cardiac surgery. Thirty had hemodynamic instability in the early POP and were monitored with the Swan-Ganz catheter. The following parameters were evaluated: cardiac index (CI), systemic and pulmonary vascular resistance, pulmonary shunt, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), oxygen delivery and consumption, use of vasoactive drugs and of circulatory support. Results - Twenty patients had low cardiac index (CI), and 10 had normal or high CI. Systemic vascular resistance was decreased in 11 patients. There was no correlation between oxygen delivery (DO2) and consumption (VO2), p=0,42, and no correlation between CVP and PCWP, p=0.065. Pulmonary vascular resistance was decreased in 15 patients and the pulmonary shunt was increased in 19. Two patients with CI< 2L/min/m2 received circulatory support. Conclusion - Patients in the OPO of cardiac surgery frequently have a mixed shock due to the systemic inflamatory response syndrome (SIRS). Therefore, invasive hemodynamic monitoring is useful in handling blood volume, choice of vasoactive drugs, and indication for circulatory support.