Preeclampsia is a multifactorial condition associated with significant morbidity and mortality. Fluid therapy in these patients is challenging since volume expansion may precipitate pulmonary edema, ...and fluid restriction may worsen renal function. Furthermore, cardiac impairment may introduce an additional component to the hemodynamic management. This article reviews the repercussions of preeclampsia on renal and cardiovascular systems and the development of pulmonary edema, as well as to discuss fluid management, focusing on the mitigation of adverse outcomes and monitoring alternatives. The literature review was carried out using PubMed, Embase, and Google Scholar databases from May 2019 to March 2020. Papers addressing the subjects of interest were included regardless of the publication language. There is a current trend towards restricting the administration of fluids in women with non-complicated preeclampsia. However, patients with preeclampsia may experience hemorrhagic shock, requiring volume resuscitation. In this case, hemodynamic monitoring is recommended to guide fluid therapy while avoiding complications.
The aim of this study was to determine whether a restrictive compared to a liberal fluid therapy will increase postoperative acute kidney injury (AKI) in patients with severe preeclampsia.
A total of ...46 patients (mean age, 32 years; standard deviation, 6.8 years) with severe preeclampsia were randomized to liberal (1500 ml of lactated Ringer's, n=23) or restrictive (250 ml of lactated Ringer's, n=23) intravenous fluid regimen during cesarean section. The primary outcome was the development of a postoperative renal dysfunction defined by AKI Network stage ≥1. Serum cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) were evaluated at postoperative days 1 and 2. ClinicalTrials.gov: NCT02214186.
The rate of postoperative AKI was 43.5% in the liberal fluid group and 43.5% in the restrictive fluid group (p=1.0). Intraoperative urine output was higher in the liberal (116 ml/h, IQR 69-191) than in the restrictive fluid group (80 ml/h, IQR 37-110, p<0.05). In both groups, serum cystatin C did not change from postoperative day 1 compared to the preoperative period and significantly decreased on postoperative day 2 compared to postoperative day 1 (p<0.05). In the restrictive fluid group, NGAL levels increased on postoperative day 1 compared to the preoperative period (p<0.05) and decreased on postoperative day 2 compared to postoperative day 1 (p<0.05).
Among patients with severe preeclampsia, a restrictive fluid regimen during cesarean section was not associated with increased postoperative AKI.
This study aimed to evaluate lung overinflation at different airway inspiratory pressure levels using computed tomography in cats undergoing general anesthesia.
Prospective laboratory study.
A group ...of 17 healthy male cats, aged 1.9-4.5 years and weighing 3.5 ± 0.5 kg.
Seventeen adult male cats were ventilated in pressure-controlled mode with airway pressure stepwise increased from 5 to 15 cmH
O in 2 cmH
O steps every 5 min and then stepwise decreased. The respiratory rate was set at 15 movements per min and end-expiratory pressure at zero (ZEEP). After 5 min in each inspiratory pressure step, a 4 s inspiratory pause was performed to obtain a thoracic juxta-diaphragmatic single slice helical CT image and to collect respiratory mechanics data and an arterial blood sample. Lung parenchyma aeration was defined as overinflated, normally-aerated, poorly-aerated, and non-aerated according to the CT attenuation number (-1,000 to -900 HU, -900 to -500 HU, -500 to -100 HU, and -100 to +100 HU, respectively).
At 5 cmH
O airway pressure, tidal volume was 6.7± 2.2 ml kg
, 2.1% (0.3-6.3%) of the pulmonary parenchyma was overinflated and 84.9% (77.6%-87.6%) was normally inflated. Increases in airway pressure were associated with progressive distention of the lung parenchyma. At 15 cmH
O airway pressure, tidal volume increased to 31.5± 9.9 ml kg
(
< 0.001), overinflated pulmonary parenchyma increased to 28.4% (21.2-30.6%) (
< 0.001), while normally inflated parenchyma decreased 57.9% (53.4-62.8%) (
< 0.001). Tidal volume and overinflated lung fraction returned to baseline when airway pressure was decreased. A progressive decrease was observed in arterial carbon dioxide partial pressure (PaCO
) and end-tidal carbon dioxide (ETCO
) when the airway pressures were increased above 9 cmH
O (
< 0.001). The increase in airway pressure promoted an elevation in pH (
< 0.001).
Ventilation with 5 and 7 cmH
O of airway pressure prevents overinflation in healthy cats with highly compliant chest walls, despite presenting acidemia by respiratory acidosis. This fact can be controlled by increasing or decreasing respiratory rate and inspiratory time.
Several studies suggest that hemodynamic optimization therapies can reduce complications, the length of hospital stay and costs. However, Brazilian data are scarce. Therefore, the objective of this ...analysis was to evaluate whether the improvement demonstrated by hemodynamic optimization therapy in surgical patients could result in lower costs from the perspective of the Brazilian public unified health system.
A meta-analysis was performed comparing surgical patients who underwent hemodynamic optimization therapy (intervention) with patients who underwent standard therapy (control) in terms of complications and hospital costs. The cost-effectiveness analysis evaluated the clinical and financial benefits of hemodynamic optimization protocols for surgical patients. The analysis considered the clinical outcomes of randomized studies published in the last 20 years that involved surgeries and hemodynamic optimization therapy. Indirect costs (equipment depreciation, estate and management activities) were not included in the analysis.
A total of 21 clinical trials with a total of 4872 surgical patients were selected. Comparison of the intervention and control groups showed lower rates of infectious (RR = 0.66; 95% CI = 0.58-0.74), renal (RR = 0.68; 95% CI = 0.54-0.87), and cardiovascular (RR = 0.87; 95% CI = 0.76-0.99) complications and a nonstatistically significant lower rate of respiratory complications (RR = 0.82; 95% CI = 0.67-1.02). There was no difference in mortality (RR = 1.02; 95% CI = 0.80-1.3) between groups. In the analysis of total costs, the intervention group showed a cost reduction of R$396,024.83-BRL ($90,161.38-USD) for every 1000 patients treated compared to the control group. The patients in the intervention group showed greater effectiveness, with 1.0 fewer days in the intensive care unit and hospital. In addition, there were 333 fewer patients with complications, with a consequent reduction of R$1,630,341.47-BRL ($371,173.27-USD) for every 1000 patients treated.
Hemodynamic optimization therapy is cost-effective and would increase the efficiency of and decrease the burden of the Brazilian public health system.
Simplified Acute Physiology Score 3 (SAPS 3) was the first critical care prognostic model developed from worldwide data. We aimed to systematically review studies that assessed the prognostic ...performance of SAPS 3 general and customized models for predicting hospital mortality in adult patients admitted to the ICU.
Medline, Lilacs, Scielo and Google Scholar were searched to identify studies which assessed calibration and discrimination of general and customized SAPS 3 equations. Additionally, we decided to evaluate the correlation between trial size (number of included patients) and the Hosmer-Lemeshow (H-L) statistics value of the SAPS 3 models.
A total of 28 studies were included. Of these, 11 studies (42.8%) did not find statistically significant mis-calibration for the SAPS 3 general equation. There was a positive correlation between number of included patients and higher H-L statistics, that is, a statistically significant mis-calibration of the model (r = 0.747, P <0.001). Customized equations for major geographic regions did not have statistically significant departures from perfect calibration in 9 of 19 studies. Five studies (17.9%) developed a regional customization and in all of them this new model was not statistically different from a perfect calibration for their populations. Discrimination was at least very good in 24 studies (85.7%).
Statistically significant departure from perfect calibration for the SAPS 3 general equation was common in validation studies and was correlated with larger studies, as should be expected, since H-L statistics (both C and H) are strongly dependent on sample size This finding was also present when major geographic customized equations were evaluated. Local customizations, on the other hand, improved SAPS 3 calibration. Discrimination was almost always very good or excellent, which gives excellent perspectives for local customization when a precise local estimate is needed.
Hepatorenal syndrome (HRS) is a severe and progressive functional renal failure occurring in patients with cirrhosis and ascites. Terlipressin is recognized as an effective treatment of HRS, but it ...is expensive and not widely available. Norepinephrine could be an effective alternative. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of norepinephrine compared to terlipressin in the management of HRS.
We searched the Medline, Embase, Scopus, CENTRAL, Lilacs and Scielo databases for randomized trials of norepinephrine and terlipressin in the treatment of HRS up to January 2014. Two reviewers collected data and assessed the outcomes and risk of bias. The primary outcome was the reversal of HRS. Secondary outcomes were mortality, recurrence of HRS and adverse events.
Four studies comprising 154 patients were included. All trials were considered to be at overall high risk of bias. There was no difference in the reversal of HRS (RR = 0.97, 95% CI = 0.76 to 1.23), mortality at 30 days (RR = 0.89, 95% CI = 0.68 to 1.17) and recurrence of HRS (RR = 0.72; 95% CI = 0.36 to 1.45) between norepinephrine and terlipressin. Adverse events were less common with norepinephrine (RR = 0.36, 95% CI = 0.15 to 0.83).
Norepinephrine seems to be an attractive alternative to terlipressin in the treatment of HRS and is associated with less adverse events. However, these findings are based on data extracted from only four small studies.
Purpose
Percutaneous dilational tracheostomy (PDT) is routinely performed in the intensive care unit with bronchoscopy guidance. Recently, ultrasound has emerged as a potentially useful tool to ...assist PDT and reduce procedure-related complications.
Methods
An open-label, parallel, non-inferiority randomized controlled trial was conducted comparing an ultrasound-guided PDT with a bronchoscopy-guided PDT in mechanically ventilated critically ill patients. The primary outcome was procedure failure, defined as a composite end-point of conversion to a surgical tracheostomy, unplanned associated use of bronchoscopy or ultrasound during PDT, or the occurrence of a major complication.
Results
A total of 4965 patients were assessed for eligibility. Of these, 171 patients were eligible and 118 underwent the procedure, with 60 patients randomly assigned to the ultrasound group and 58 patients to the bronchoscopy group. Procedure failure occurred in one (1.7 %) patient in the ultrasound group and one (1.7 %) patient in the bronchoscopy group, with no absolute risk difference between the groups (90 % confidence interval, −5.57 to 5.85), in the “as treated” analysis, not including the prespecified margin of 6 % for noninferiority. No other patient had any major complication in either group. Procedure-related minor complications occurred in 20 (33.3 %) patients in the ultrasound group and in 12 (20.7 %) patients in the bronchoscopy group (
P
= 0.122). The median procedure length was 11 7–19 vs. 13 8–20 min (
P
= 0.468), respectively, and the clinical outcomes were also not different between the groups.
Conclusions
Ultrasound-guided PDT is noninferior to bronchoscopy-guided PDT in mechanically ventilated critically ill patients.
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