[Cerebral hemometabolism: variability in the acute phase of traumatic coma]. / Hemometabolismo cerebral: variações na fase aguda do coma traumático.

OBJECTIVE: to evaluate the interrelationships between cerebral and systemic hemometabolic alterations in patients with severe traumatic brain injury managed according to a standardized therapeutic protocol. DESIGN: prospective, interventional study in patients with traumatic coma. SETTING: a general Intensive Care Unit in a teaching hospital. PATIENTS AND METHODS: twenty-seven patients (21M e 6F), aging 14 - 58 years, with severe acute brain trauma, presenting with three to eight points on the Glasgow Coma Scale, were prospectively evaluated according to a cumulative protocol for the management of acute intracranial hypertension, where intracranial pressure (ICP) and cerebral extraction of oxygen (CEO2) were routinely measured. Hemometabolic interrelationships involving mean arterial pressure (MAP), ICP, arterial carbon dioxide tension (PaCO2), CEO2, cerebral perfusion pressure (CPP) and systemic extraction of oxygen (SEO2) were analyzed. INTERVENTIONS: routine therapeutic procedures. RESULTS: no correlation was found between CEO2 and CPP (r = -0.07; p = 0.41). There was a significant negative correlation between PaCO2 and CEO2 (r = -0.24; p = 0.005) and a positive correlation between SEO2 and CEO2 (r = 0.24; p = 0.01). The mortality rate in this group of patients was 25.9% (7/27). CONCLUSION: 1) CPP and CEO2 are unrelated; 2) CEO2 and PaCO2 are closely related; 3) during optimized hyperventilation, CEO2 and SEO2 are coupled.

Complicaçöes cardiocirculatórias no acidente vascular cerebral e no traumatismo cranioencefálico / Cardiocirculatory complications in acute stroke and head trauma

O sistema nervoso central tem importante papel na regulação da atividade cardíaca e do tônus vasomotor. Lesöes neurológicas centrais que levem a distúrbios da atividade autonômica, como acidentes vasculares cerebrais e traumatismo cranioencefálico, tendem a causar evidências eletrocardiográficas e patológicas de lesão miocárdica, arritmias cardíacas e alteraçöes na regulação da pressão arterial. Observaçöes em unidades de terapia intensiva têm demonstrado que pacientes em recuperaçäo de lesöes cerebrais agudas muitas vezes perecem inesperadamente de complicaçöes cardíacas ou morte súbita. Quando comparados a controles, os pacientes com doenças agudas do sistema nervoso central apresentam mais frequentemente arritmias, aumento de enzimas cardíacas e elevaçäo dos níveis plasmáticos de noradrenalina, sugerindo hiperatividade simpática. Observaçöes recentes têm demonstrado que o envolvimento do córtex insular, no infarto cerebral experimental, é crucial na mediaçäo de complicaçöes cardíacas. O comprometimento do córtex cerebral direito, mais do que o do esquerdo, representa risco adicional para o desencadeamento dessas complicaçöes. A eficácia do bloqueio autonômo na prevençäo do dano miocárdico tem sido demonstrada experimentalmente na hemorragia intracerebral em animais. E sugerido que o uso precoce de drogas bloqueadoras autonômas, em pacientes com lesöes cerebrais agudas, pode ser útil no manuseio das complicaçöes cardíacas.

Semiquantitative culture in diagnosing venous catheter-related sepsis.

Since Aubaniac (1) described the puncture of the subclavian vein in 1952, and specially after the standardization of parenteral nutrition by Dudrick et al. (11) in 1968, much has been published about complications caused by percutaneous central venous catheterization. Among the various complications provoked by this procedure, a very important one is "primary sepsis" or "catheter-related sepsis", both because of its frequency and because of the morbidity and mortality it causes (18,19). It is, however, difficult to diagnose this complication. The main difficulty lies in differentiating catheters that are really causing sepsis from those that, though showing "positive culture" do not cause bacteremia and are not responsible for the occasional signs of infection that a patient may show (6,7). This difficulty in diagnosing has led to the recommendation that all catheters suspected of causing sepsis be systematically removed. This procedure has the effect of exposing patients in serious condition and with limited venous access to the risks of new punctures. Usually these risks are unnecessary, since 75 to 90% of the catheters removed for this reason are not the real source of infection (3, 17, 19, 21, 22). In 1977, Maki et al. (18) proposed a semiquantitative catheter tip culture that showed considerable correlation with positive hemoculture for the same microorganisms; that is, capable of identifying which "positive catheters" were really causing sepsis. Subsequent research confirmed these results, showing that the semiquantitative catheter tip culture had specificity and sensibility over 80% (10, 15).(ABSTRACT TRUNCATED AT 250 WORDS)

[Ogilvie syndrome in 2 cases of pseudo-pseudo-obstruction of the colon]. / Considerações sobre a síndrome de Ogilvie a partir de dois casos de pseudo-pseudo-obstrução do cólon.

Ogilvie's syndrome is defined as a pseudo-obstruction of the colon of unknown cause. A review of recent literature shows a proliferation of reports of such cases associated to multiple conditions. The authors present two cases of perforated peptic ulcers with peritonitis that mimicked Ogilvie's syndrome in the clinical, radiological, and colonoscopic presentations. They propose that pseudo-obstruction cases obviously caused by adynamic ileus be excluded from the Ogilvie's syndrome classification, for a better understanding of its pathogenesis.

Síndrome de angústia respiratória do adulto: primeira parte / Adult respiratory distress syndrome: I part

Os autores fazem uma revisäo da síndrome de angústia respiratória do adulto, desde a vasta sinonímia desta entidade que tem uma fisiopatologia. Os autores abordam os principais fatores desencadeantes e discutem os critérios diagnósticados mais empregados na clínica: critérios clínicos, radiológicos, fisiológicos, anatomopatológicos. As fases de membrana hialina e de fibrose pulmonar säo discutidas, bem como a síndrome de Mendelson

Algoritmos cardiorrespiratórios para UTI / Cardiorespiratory algorithms for intensive care

Apresentam-se os algoritmos utilizados no programa de avaliaçäo cardiorrespiratória, desenvolvido em micro-computador de 8 bits e 64 Kbytes de RAM. Além dos parâmetros convencionais, säo dados de entrada, o débito cardíaco e a pressäo capilar pulmonar, obtidos por monitoramento invasivo. Isto permite a aquisiçäo de parâmetros de desempenho ventricular esquerdo e das resistências sistêmica e pulmonar. Introduzindo dados de gasometria arterial e venosa permitem, ainda, a obtençäo de dados essenciais, como o consumo de oxigênio e o shunt pulmonar, assim como o gradiente alvéolo-arterial e a relaçäo artério-alveolar. O sistema já se encontra em uso há seis meses. A disponibilidade imediata destes parâmetros em situaçöes críticas, visa oferecer ao intensivista maiores subsídios na tomada de decisöes