Abstract Purpose The aims of this study are to determine the general relationship of perfused vessel density (PVD) to mortality and organ dysfunctions and to explore if patients in the lowest ...quartile of distribution for this parameter present a higher risk of bad outcome and to identify systemic hemodynamic and perfusion variables that enhances the probability of finding a severe underlying microvascular dysfunction. Materials and Methods This is a retrospective multicenter study including 122 septic shock patients participating in 7 prospective clinical trials on which at least 1 sublingual microcirculatory assessment was performed during early resuscitation. Results Perfused vessel density was significantly related to organ dysfunctions and mortality, but this effect was largely explained by patients in the lowest quartile of distribution for PVD ( P = .037 odds ratio {OR}, 8.7; 95% confidence interval {CI}, 1.14-66.78 for mortality). Hyperlactatemia ( P < .026 OR, 1.23; 95% CI, 1.03-1.47) and high norepinephrine requirements ( P < .019 OR, 7.04; 95% CI, 1.38-35.89) increased the odds of finding a severe microvascular dysfunction. Conclusions Perfused vessel density is significantly related to organ dysfunctions and mortality in septic shock patients, particularly in patients exhibiting more severe abnormalities as represented by the lowest quartile of distribution for this parameter. The presence of hyperlactatemia and high norepinephrine requirements increases the odds of finding a severe underlying microvascular dysfunction during a sublingual microcirculatory assessment.
Este trabajo analiza, desde una perspectiva histórica y artística, la evolución de los conceptos “Trabajo” y “Trabajadores” durante los primeros años del muralismo mexicano, periodo que buscó ...reconfigurar la identidad nacional conjugando valores de la Revolución en curso. A través de Alegoría del Trabajo (1910) de Saturnino Herrán, identificado como el pionero del muralismo en México, y la monumental obra de Diego Rivera en la Secretaría de Educación Pública (1923); se pudo evidenciar que en trece años la estructura fabril mantuvo sus aspectos centrales, sin embargo, el nacionalismo revolucionario transformó la concepción respecto a los trabajadores mezclando lo indígena, lo popular y la militancia política de los artistas y obreros.
Introduction. A subgroup of septic shock patients will never develop hyperlactatemia despite being subjected to a massive circulatory stress. Maintenance of normal lactate levels during septic shock ...is of great clinical and physiological interest. Our aim was to describe the clinical, hemodynamic, perfusion, and microcirculatory profiles associated to the absence of hyperlactatemia during septic shock resuscitation. Methods. We conducted an observational study in septic shock patients undergoing resuscitation. Serial clinical, hemodynamic, and perfusion parameters were registered. A single sublingual microcirculatory assessment was performed in a subgroup. Patients evolving with versus without hyperlactatemia were compared. Results. 124 septic shock patients were included. Patients without hyperlactatemia exhibited lower severity scores and mortality. They also presented higher platelet counts and required less intensive treatment. Microcirculation was assessed in 45 patients. Patients without hyperlactatemia presented higher PPV and MFI values. Lactate was correlated to several microcirculatory parameters. No difference in systemic flow parameters was observed. Conclusion. Persistent sepsis-induced hypotension without hyperlactatemia is associated with less organ dysfunctions and a very low mortality risk. Patients without hyperlactatemia exhibit less coagulation and microcirculatory derangements despite comparable macrohemodynamics. Our study supports the notion that persistent sepsis-induced hypotension without hyperlactatemia exhibits a distinctive clinical and physiological profile.
La dimensión cultural como parte del currículo para la adquisición de segundas lenguas ha sido un tema de interés en los últimos años, debido a su función unificadora de los significados que emergen ...a través del uso de una lengua. El objetivo del presente artículo es analizar la dimensión cultural de un programa de adquisición de segundas lenguas (ASLs) que busca promover el desarrollo de la comunicación intercultural, en contexto migratorio. Para ello, se analizan cualitativamente seis entrevistas semiestructuradas que fueron aplicadas a profesionales del área de la salud que son parte de un curso de adquisición del criollo haitiano en Chile. Dicho análisis se lleva a cabo a través del sofware NVIVO10. Desde este análisis se desprende la importancia del rol de los mediadores lingüísticos y los artefactos culturales como elementos constituyentes de apropiación de esta dimensión en la adquisición de segundas lenguas. Palabras claves: mediador lingüístico, artefactos culturales, programa educativo, integración, lengua criollo haitiano. The cultural dimension as part of the curricula for the acquisition of second languages (ASLs) has been a trending topic during these last years due to the unifying function of meanings that emerge while using a language. The objective of this article is to analyze the cultural dimension of a second language acquisition program that promotes the development of intercultural communication in a migratory context. To carry out this study, six health professionals, who were students from an acquisition course of the Haitian Creole in Chile, were interviewed. The semi-structured interviews were analyzed using the NVIVO10 software. From this analysis emerges the importance of the role of linguistic mediators and cultural artifacts as constituent elements of appropriation of this dimension in the acquisition of second languages. Key words: linguistic mediator, cultural artifacts, educational program, integration, Haitian Creole language.
RESUMEN: La dimensión cultural como parte del currículo para la adquisición de segundas lenguas ha sido un tema de interés en los últimos años, debido a su función unificadora de los significados que ...emergen a través del uso de una lengua. El objetivo del presente artículo es analizar la dimensión cultural de un programa de adquisición de segundas lenguas (ASLs) que busca promover el desarrollo de la comunicación intercultural, en contexto migratorio. Para ello, se analizan cualitativamente seis entrevistas semiestructuradas que fueron aplicadas a profesionales del área de la salud que son parte de un curso de adquisición del criollo haitiano en Chile. Dicho análisis se lleva a cabo a través del sofware NVIVO10. Desde este análisis se desprende la importancia del rol de los mediadores lingüísticos y los artefactos culturales como elementos constituyentes de apropiación de esta dimensión en la adquisición de segundas lenguas.
Purpose
The role of dobutamine during septic shock resuscitation is still controversial since most clinical studies have been uncontrolled and no physiological study has unequivocally demonstrated a ...beneficial effect on tissue perfusion. Our objective was to determine the potential benefits of dobutamine on hemodynamic, metabolic, peripheral, hepatosplanchnic and microcirculatory perfusion parameters during early septic shock resuscitation.
Methods
We designed a randomized, controlled, double-blind, crossover study comparing the effects of 2.5-h infusion of dobutamine (5 mcg/kg/min fixed-dose) or placebo in 20 septic shock patients with cardiac index ≥2.5 l/min/m
2
and hyperlactatemia. Primary outcome was sublingual perfused microvascular density.
Results
Despite an increasing cardiac index, heart rate and left ventricular ejection fraction, dobutamine had no effect on sublingual perfused vessel density 9.0 (7.9–10.1) vs. 9.1 n/mm (7.9–9.9);
p
= 0.24 or microvascular flow index 2.1 (1.8–2.5) vs. 2.1 (1.9–2.5);
p
= 0.73 compared to placebo. No differences between dobutamine and placebo were found for the lactate levels, mixed venous-arterial pCO
2
gradient, thenar muscle oxygen saturation, capillary refill time or gastric-to-arterial pCO
2
gradient. The indocyanine green plasma disappearance rate 14.4 (9.5–25.6) vs. 18.8 %/min (11.7–24.6);
p
= 0.03 and the recovery slope of thenar muscle oxygen saturation after a vascular occlusion test 2.1 (1.1–3.1) vs. 2.5 %/s (1.2–3.4);
p
= 0.01 were worse with dobutamine compared to placebo.
Conclusions
Dobutamine failed to improve sublingual microcirculatory, metabolic, hepatosplanchnic or peripheral perfusion parameters despite inducing a significant increase in systemic hemodynamic variables in septic shock patients without low cardiac output but with persistent hypoperfusion.
Background
The decision of when to stop septic shock resuscitation is a critical but yet a relatively unexplored aspect of care. This is especially relevant since the risks of over-resuscitation with ...fluid overload or inotropes have been highlighted in recent years. A recent guideline has proposed normalization of central venous oxygen saturation and/or lactate as therapeutic end-points, assuming that these variables are equivalent or interchangeable. However, since the physiological determinants of both are totally different, it is legitimate to challenge the rationale of this proposal. We designed this study to gain more insights into the most appropriate resuscitation goal from a dynamic point of view. Our objective was to compare the normalization rates of these and other potential perfusion-related targets in a cohort of septic shock survivors.
Methods
We designed a prospective, observational clinical study. One hundred and four septic shock patients with hyperlactatemia were included and followed until hospital discharge. The 84 hospital-survivors were kept for final analysis. A multimodal perfusion assessment was performed at baseline, 2, 6, and 24 h of ICU treatment.
Results
Some variables such as central venous oxygen saturation, central venous-arterial pCO
2
gradient, and capillary refill time were already normal in more than 70% of survivors at 6 h. Lactate presented a much slower normalization rate decreasing significantly at 6 h compared to that of baseline (4.0 3.0 to 4.9 vs. 2.7 2.2 to 3.9 mmol/L;
p
< 0.01) but with only 52% of patients achieving normality at 24 h. Sublingual microcirculatory variables exhibited the slowest recovery rate with persistent derangements still present in almost 80% of patients at 24 h.
Conclusions
Perfusion-related variables exhibit very different normalization rates in septic shock survivors, most of them exhibiting a biphasic response with an initial rapid improvement, followed by a much slower trend thereafter. This fact should be taken into account to determine the most appropriate criteria to stop resuscitation opportunely and avoid the risk of over-resuscitation.
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