Embolization in patient with hypovolemic shock after transobturator sling procedure / Embolização após sling transobturatório em paciente com choque hipovolêmico

Abstract The placement of a suburethral sling is standard treatment for stress urinary incontinence. The transobturator technique (TOT) emerged as an alternative to minimize the risks of the blind insertion of needles, leading to a lower rate of perforation complications compared with the retropubic approach. We present a case of injury to a branch of the left obturator artery following the placement of a urethral sling using TOT, followed by intense bleeding and hemodynamic instability, which was treated with embolization.

Resumo Sling de uretra média é o tratamento padrão para a incontinência urinária de esforço. A abordagem transobturatória (TOT) surgiu como alternativa para minimizar os riscos da inserção às cegas das agulhas com taxa de complicações perfurativas menores quando comparadas à abordagem retropúbica. Apresentamos um caso de lesão em ramo da artéria obturatória esquerda após sling TOT que evoluiu com sangramento intenso e instabilidade hemodinâmica, sendo tratado com embolização.

Temperature gradients in domestic cats over seven-years-old: descriptive analysis / Avaliação descritiva dos gradientes de temperatura em felinos domésticos com mais de sete anos

The temperature gradients are dynamic and noninvasive monitoring techniques that provide information on peripheral blood flow and have been related to the prognosis of patients with circulatory shock. This study evaluated 47 elderly domestic cats' temperature gradients, and we measured central (rectal) and peripheral (palmar, plantar and medial region of the radio) temperatures. Values found in this study are compatible with studies in young felines and differ from dogs and humans. The mean gradients found were 7.5°C for the central-peripheral; 5.6°C for the peripheral-environmental; 2.7°C for the skin-diff; and 0°C for the member-diff and the variables age and gender do not seem to influence these measurements. To the authors' knowledge, there is no description of temperature gradients in elderly domestic cats, so this study pretends to clarify the vasoconstriction response in this group of animals.(AU)

Os gradientes de temperatura são técnicas de monitoração dinâmicas e não-invasivas que fornecem informações sobre o fluxo sanguíneo periférico, e têm sido relacionados ao prognóstico de paciente com choque circulatório. O presente estudo avaliou os gradientes de temperatura em 47 felinos domésticos idosos aferindo as temperaturas central (retal) e periférica (palmar, plantar e região medial do rádio). Os gradientes encontrados foram 7,5°C para o centro-periférico; 5,6°C para o periférico-ambiental; 2,7°C para o skin-diff; e 0°C para o member-diff. As variáveis idade e sexo não pareceram influenciar as mensurações. Não há, em conhecimento dos autores, descrição prévia dos gradientes de temperatura em felinos domésticos idosos, e por isso esse estudo pretende contribuir com o entendimento sobre a capacidade de resposta de vasoconstrição nesse grupo de animais.(AU)

Mycotic aneurysm with aortoduodenal fistula

Firstly described in the 19th century by Sir William Osler, the mycotic aneurysm (MA) is a rare entity characterized by an abnormal arterial dilation, which is potentially fatal, and is associated with the infection of the vascular wall. Elderly patients are mostly involved, especially when risk factors like chronic diseases, immunosuppression, neoplasia, and arterial manipulation are associated. The authors report the case of a young male patient diagnosed with an aortic aneurysm of infectious origin in the presence of repeated negative blood cultures. The diagnostic hypothesis was raised when the patient was hospitalized for an inguinal hernia surgery. The diagnosis was confirmed based on imaging findings consistent with mycotic aneurism. The patient was treated with an endovascular prosthesis associated with a long-lasting antibiotic therapy. Five months later, the patient attended the emergency unit presenting an upper digestive hemorrhage and shock, from which he died. The autopsy revealed a huge aneurysm of the abdominal aorta with an aortoduodenal fistula. The histological examination of the arterial wall revealed a marked inflammatory process, extensive destruction of the arterial wall, and the presence of Gram-positive bacteria. This case highlights the atypical presentation of a MA associated with an aortoduodenal fistula. Besides the early age of the patient, no primary arterial disease could be found,and no source of infection was detected.

Pathological Substratum for a Case of Fulminant Myocarditis Treated with Extracorporeal Membrane Oxygenation and Subsequent Heart Transplantation

Fulminant myocarditis has been defined as the clinical manifestation of cardiac inflammation with rapid-onset heart failure and cardiogenic shock. We report on the case of a 23-yr-old woman with pathology-proven fulminant lymphocytic myocarditis presenting shock with elevated cardiac troponin I and ST segments in V1-2, following sustained ventricular tachycardia and a complete atrioventricular block. About 55 min of intensive cardio-pulmonary resuscitation, with extracorporeal membrane oxygenation support, bridged the patient to orthotopic heart transplantation. The explanted heart revealed diffuse lymphocytic infiltration and myocyte necrosis in all four cardiac chamber walls. Aggressive mechanical circulatory support may be an essential bridge for recovery or even transplantation in patients with fulminant myocarditis with shock.

The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunction

BACKGROUND/AIMS: Ascites is a dreadful complication of liver cirrhosis associated with short survival. Large volume paracentesis (LVP) is used to treat tense or refractory ascites. Paracentesis induced circulatory dysfunction (PICD) develops if no plasma expanders are given with ominous complications. To study the effect of ascites flow rate on PICD development. METHODS: Sixty patients with cirrhosis and tense ascites underwent LVP of 8 L were randomized into 3 equal groups of different flow rate extraction; group I (80 mL/minute), group II (180 mL/minute) and group III (270 mL/minute). Plasma renin activity (PRA) was measured baseline and on day six. PICD was defined as increase in PRA >50% of the pretreatment value. RESULTS: In group I through 3; the mean age was (52.5±9.4 vs. 56.4±8.5 vs. 55.8±7.1 years; P>0.05), mean arterial pressure (81.4±5.6 vs. 81.5±7 vs. 79.5±7.2 mmHg; P>0.05), MELD (17.6±4.1 vs. 15.8±4.1 vs. 14.7±4.5). Baseline PRA was comparable (1,366.0±1244.9 vs. 1,151.3±1,444.8 vs. 951.9±1,088 pg/mL; P>0.05). There was no statistically significant (P>0.05) flow mediated changes (Delta) of creatinine (0.23±0.27 vs. 0.38±0.33 vs. 0.26±0.18 mg/dL), MELD (1.25±5.72 vs. 1.70±2.18 vs. 1.45±2.21) or PRA (450.93±614.10 vs. 394.61±954.64 vs. 629.51±1,116.46 pg/mL). PICD was detected in a similar frequency in the three groups (P>0.05). On univariate logistic analysis only female sex was a fairly significant PICD predictor (Wald 3.85, odds ratio 3.14; P=0.05). CONCLUSIONS: The ascites flow rate does not correlate with PICD development.

Falta de concordância entre diferentes observadores e métodos na mensuração do tempo de reenchimento capilar em voluntários saudáveis: estudo observacional / Lack of agreement between different observers and methods in the measurement of capillary refill time in healthy volunteers: an observational study

Objetivo: As anomalias da perfusão periférica são manifestações importantes do choque, sendo o tempo de reenchimento capilar comumente utilizado em sua avaliação. Entretanto, a reprodutibilidade das mensurações do tempo de reenchimento capilar e sua correlação com outras variáveis da perfusão periférica não foram avaliadas de forma abrangente. Nosso objetivo foi determinar, em voluntários saudáveis, a concordância entre diferentes métodos e diferentes observadores na quantificação do tempo de reenchimento capilar, assim como sua correlação com outros marcadores da perfusão periférica. Métodos: Estudamos 63 voluntários saudáveis. Dois observadores mediram o tempo de reenchimento capilar por meio de dois métodos distintos: visão direta (TRCcronômetro) e vídeo-análise (TRCvídeo). Medimos também o índice de perfusão derivado de pletismografia de pulso e a temperatura da polpa digital (Tºperiférica). A concordância entre os observadores e os métodos foi avaliada utilizando o método de Bland-Altman. As correlações foram calculadas utilizando a correlação de Pearson. Valor de p<0,05 foi considerado significante. Resultados: Os limites de concordância de 95% entre ambos os observadores foram de 1,9 segundo para TRCcronômetro e 1,7 segundo para TRCvídeo. Os limites de concordância de 95% entre TRCcronômetro e TRCvídeo foram de 1,7 segundo para o Observador 1 e 2,3 segundos para o Observador 2. As mensurações do TRCcronômetro realizadas pelos dois observadores se correlacionaram com a Tºperiférica. As mensurações do TRCvídeo realizadas pelos dois observadores se correlacionaram com a Tºperiférica e o índice de perfusão. ...

Objective: Peripheral perfusion abnormalities are relevant manifestations of shock. Capillary refill time is commonly used for their evaluation. However, the reproducibility of capillary refill time measurements and their correlation with other variables of peripheral perfusion, have not been comprehensively evaluated. Our goal was to determine, in healthy volunteers, the agreement between different methods of capillary refill time quantification and different observers, as well as their correlation with other markers of peripheral perfusion. Methods: We studied 63 healthy volunteers. Two observers measured capillary refill time by means of two methods, direct view (CRTchronometer) and video analysis (CRTvideo). We also measured perfusion index (PI) derived from pulse plethysmography and finger pad temperature (Tºperipheral). The agreement between observers and methods was assessed using the Bland and Altman method. Correlations were calculated using Pearson's correlation. A p-value<0.05 was considered significant. Results: The 95% limits of agreement between the two observers were 1.9 sec for CRTchronometer and 1.7 sec for CRTvideo. The 95% limits of agreement between CRTchronometer and CRTvideo were 1.7 sec for observer 1 and 2.3 sec for observer 2. Measurements of CRTchronometer performed by the two observers were correlated with Tºperipheral. Measurements of CRTvideo performed by the two observers were correlated with Tºperipheral and perfusion index. Conclusion: In healthy volunteers, measurements of capillary refill time performed by either different observers or different methods showed poor agreement. Nevertheless, capillary refill time still reflected peripheral perfusion as shown by its correlation with objective variables of peripheral perfusion. .

Choque: princípios gerais de diagnóstico precoce e manejo inicial / Shock: general principles of early diagnosis and initial management

O choque circulatório é uma síndrome caracterizada por uma inadequada perfusão tecidual sistêmica, e se não diagnosticado e manejado precocemente, pode levar a falência múltipla de órgãos e a altos índices de mortalidade. Este artigo objetiva revisar de forma breve e sistemática os tipos de choque, suas apresentações e diagnóstico, além do manejo inicial na sala de emergência

Shock is a syndrome characterized by inadequate tissue perfusion, and if not early diagnosed and managed, can lead to multiple organ failure and high mortality rates. This review focuses briefly and systematically in the types of shock, their presentations and diagnosis, beyond the initial management in the emergency room.

Choque em crianças / Shock in children

Este texto apresenta uma revisão da definição, classificação, fisiopatologia e tratamento inicial dos diversos tipos de choque na criança. O reconhecimento precoce e o tratamento agressivo do choque em tempo oportuno são essenciais à prevenção da parada cardiorrespiratória e à melhora do desfecho

This paper presents a review of the definition, classification, pathophysiology and initial management of the different types of shock in children. Early recognition and aggressive treatment of shock in a timely manner are essential to the prevention of cardiopulmonary arrest and out come improvement.

Segundo Consenso Clínico de la Sociedad Iberoamericana de Neonatología: manejo hemodinámico del recién nacido / Second Clinical Consensus of the Ibero-American Society of Neonatology: hemodynamic management of newborns

Este trabajo informa acerca del proceso y los resultados del Segundo Consenso Clínico de la SIBEN (Sociedad Iberoamericana de Neonatología), en el cual 80 neonatólogos de 23 países fueron invitados a participar y colaborar. Se desarrollaron varias preguntas de importancia clínico-fisiológica sobre el manejo hemodinámico del recién nacido. Los participantes fueron distribuidos en grupos, facilitando así la interacción y el trabajo conjunto, con la consigna de responder de tres a cinco preguntas mediante el análisis de bibliografía y factores locales. El Grupo de Consenso se reunió en Mar del Plata, Argentina, donde se llevaron a cabo diversas ponencias, debates y presentaciones. En total participaron 54 neonatólogos de 21 países, con el objetivo de desarrollar un consenso sobre aspectos que incluyeron conceptos y definiciones de inestabilidad hemodinámica, la fisiopatología del cuadro de compromiso hemodinámico, las estrategias terapéuticas recomendadas y el monitoreo hemodinámico. Se espera que esta experiencia internacional sirva como una iniciativa útil tanto para la búsqueda de futuros consensos como para reducir las disparidades existentes entre los tratamientos y resultados de los diferentes países de la Región.

This study reports on the process and results of the Second Clinical Consensus of the Ibero-American Society of Neonatology. Eighty neonatologists from 23 countries were invited to collaborate and participate in the event. Several questions of clinical-physiological importance in the hemodynamic management of newborns were addressed. Participants were divided into groups to facilitate interaction and teamwork, with instructions to respond to three to five questions by analyzing the literature and local factors. Meeting in Mar del Plata, Argentina, the Consensus Group served as a form for various presentations and discussions. In all, 54 neonatologists from 21 countries attended, with the objective of reaching a consensus on such matters as concepts and definitions of hemodynamic instability, the physiopathology of hemodynamic compromise, recommended therapy strategies, and hemodynamic monitoring. It is hoped that this international experience will serve as a useful initiative for future consensus building and reduction of the existing disparities among the countries of the Region in terms of treatment and outcomes.

Choque circulatório / Circulatory Shock

São apresentados os aspectos práticos da fisiologia cardiovascular e do sistemacirculatório para a compreensão das anormalidades hemodinâmicas nos diferentes quadros dechoque circulatório. Também são apresentados os métodos terapêuticos básicos para o choquecirculatório.

Practical physiological aspects of both the cardiovascular and the circulatorysystem, which help to give an insight into the hemodynamic abnormalities that underlie the differentsymptoms of circulatory shock, are presented. Furthermore, basic therapeutic methods for thetreatment of circulatory shocks are discussed.

Siriraj score as a tool for clinical diagnosis of stroke

Siriraj stroke score is a diagnostic tool to differentiated ischemic from haemorrhagic shock. This study was carried out to access SSS accuracy as compared to CT scan. This study was carried out in the Department of Medicine and Neurology of Mayo Hospital, Lahore. Thirty two patients were included in the study who had stroke SSS was applied as well as CT scan was done. Out of them 6% were misdiagnosed. Overall predictive accuracy was 87.5%. Siriraj stroke score is not 100% accurate. CT scan should be advised before starting definitive stroke therapy

Lactato sérico como marcador prognóstico em criancas gravemente doentes / Blood lactate concentration as prognostic marker in critically ill children

OBJETIVO: Verificar a utilidade do lactato como marcador de hipoperfusão tecidual e como índice prognóstico em criancas criticamente doentes. MÉTODOS: Estudo prospectivo, longitudinal, tipo observacional de 75 pacientes admitidos na UTI pediátrica do Hospital de Clínicas (UFPR) entre novembro de 1998 e maio de 1999. De acordo com o nível de lactato na admissão, os pacientes foram divididos em grupo A (lactato > 18 mg/dl) e grupo B (lactato < 18 mg/dl). Com relacão à evolucão, em sobrevivente e óbito. No grupo A, a avaliacão clínica e a coleta de amostras de sangue arterial foram realizadas na admissão, 6, 12, 24, 48 horas e, posteriormente, a cada 24 horas. No grupo B, foram realizadas nos mesmos horários e interrompidas com 48 horas após admissão. RESULTADOS: No grupo A, foram incluídos 50 pacientes, e no Grupo B, 25. O grupo A apresentou maior freqüência de sinais clínicos de hipoperfusão (24/50). Houve diferenca estatisticamente significativa da média de lactato na admissão entre os pacientes que foram a óbito nas primeiras 24 horas de internacão (95 mg/dl) quando comparados àqueles que evoluíram a óbito após 24 horas de admissão (28 mg/dl). O nível de lactato na avaliacão de 24 horas de UTI foi o que apresentou melhor sensibilidade (55,6 por cento) e especificidade (97,2 por cento) como parâmetro preditor de óbito. CONCLUSÕES: A maioria dos pacientes com lactato > 18 mg/dl evidenciou sinais clínicos de hipoperfusão na admissão. A normalizacão ou diminuicão dos níveis de lactato a partir de 24 horas de internacão esteve significativamente relacionada com a maior probabilidade de sobrevida.

Pediatric Advanced Life Support (PALS): the current guidelines.

Every 5 years the American Heart Association (AHA) updates the Guidelines for CPR and Emergency Cardiovascular Care (ECC). The ECC Guidelines 2000 incorporates all the current consensus of experts, from not only a variety of disciplines, but also a variety of countries and cultures and is evidence based. The new Guidelines emphasize interventions to reduce the risk of sudden deaths, early identification of respiratory failure and shock and implementation of Advanced Life Support (ALS) to treat respiratory and cardiac arrest.

Peripheral circulatory failure.

Shock is a syndrome arising from any of several initiating causes, resulting in inadequate tissue perfusion. Untreated shock due to any cause can lead to irreversible cellular damage. Early diagnosis and intervention are, therefore, key to improved outcomes. In children, hypotension is not a sensitive marker for diagnosing peripheral circulatory failure. A detailed evaluation to assess perfusion particularly estimating capillary refill time and end organ perfusion is required. Septic shock is a complex condition with varying contribution of hypovolemia, cardiac dysfunction and distributive shock. Aggressive fluid therapy in the early stages is essential to recovery. Understanding the pathophysiology will help in judicious use of vasoactive drugs. Newer modalities of treatment for severe sepsis and septic shock still need evaluation in children.

A síndrome do choque circulatório / Circulatory shock syndrome

O choque circulatório é marcado por reduçöes críticas na perfusäo tecidual, provocando alteraçöes sistêmicas graves, com comprometimento da funçäo celular e orgânica, com alto índice de mortalidade. O diagnóstico e a instituiçäo de medidas terapêuticas devem ser precoces e baseados na resposta individual de cada paciente, dando-se ênfase ao suporte ventilatório e hemodinâmico. O conhecimento profundo da sua fisiopatologia norteia as decisöes terapêuticas, uma vez que através dela se estabelecem objetivos a serem atingidos. Diversas condutas recentes estäo sendo pesquisadas em pacientes com choque circulatório. Estas medidas incluem reposiçöes volêmicas, simples, soluçöes substitutas de hemácias e terapias dirigidas aos mediadores (citocinas, endotoxinas, prostaglandinas, leucotrienos e fator de ativaçäo plaquetária).

Hemorrhagic syndrome and acute renal failure in a pregnant woman after contact with Lonomia caterpillars: a case report

Um caso de uma gestante de 37 semanas que desenvolveu uma sindrome hemorragica e insuficiência renal aguda apos contato com lagartas do genero Lonomia e relatado. O acidente desencadeou trabalho de parto prematuro e a paciente deu a luz a um recém nascido vivo. Alguns aspectos fisiopatologicos do sangramento genital e da insuficiência renal aguda säo discutidos