RESUMO
Introduction: Critically ill patients undergoing extracorporeal membrane oxygenation (ECMO) exhibit unique pharmacokinetics. This study aimed to assess the achievement of vancomycin therapeutic targets in these patients. Methods: This retrospective cohort study included patients on ECMO treated with vancomycin between January 2010 and December 2018. Ninety patients were analyzed based on ECMO connection modality, baseline creatinine levels, estimated glomerular filtration rate (eGFR), renal replacement therapy (RRT) requirements, and vancomycin loading dose administration. Results: Twenty-three percent of the patients achieved the therapeutic range defined by baseline levels. No significant differences in meeting the therapeutic goal were found in multivariate analysis considering ECMO cannulation modality, initial creatinine level, initial eGFR, RRT requirement, or loading dose use. All trough levels between 15 and 20â mcg/mL achieved an estimated area under the curve/minimum inhibitory concentration (AUC/MIC) between 400 and 600, almost all trough levels over 10â mcg/mL predicted an AUC/MIC >400. Discussion: Achieving therapeutic plasma levels in these patients remains challenging, potentially due to factors such as individual pharmacokinetics and pathophysiology. A trough plasma level between 12 and 20 estimated the therapeutic AUC/MIC for all models, proposing a possible lower target, maintaining exposure, and potentially avoiding adverse effects. Despite being one of the largest cohorts of vancomycin use in ECMO patients studied, its retrospective nature and single-center focus limits its broad applicability.
Assuntos
Antibacterianos , Estado Terminal , Oxigenação por Membrana Extracorpórea , Vancomicina , Humanos , Vancomicina/farmacocinética , Vancomicina/administração & dosagem , Vancomicina/sangue , Estudos Retrospectivos , Estado Terminal/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Antibacterianos/farmacocinética , Antibacterianos/administração & dosagem , Antibacterianos/sangue , Adulto , Idoso , Área Sob a Curva , Taxa de Filtração Glomerular , Terapia de Substituição Renal/métodos , Creatinina/sangueRESUMO
INTRODUCCION. La fistula palatina es la persistencia de comunicación anormal entre la cavidad nasal y oral post palatoplastia, es la complicación frecuente con: alta morbilidad, problemas para la alimentación, articulación de las palabras inapropiada, halitosis hasta problemas psicosociales como baja autoestima y rechazo social. OBJETIVO. Determinar los factores asociados al desarrollo de fístula palatina. MATERIALES Y MÉTODOS. Estudio observacional, analítico de casos y controles. De una población de 334 Historias Clínicas se tomó muestra de 89 en la Unidad de Plástica y Reconstructiva del Hospital de Especialidades Carlos Andrade Marín de enero 2010 a julio 2019. Criterios de inclusión: datos de pacientes con paladar fisurado reparado por palatoplastia. Criterios de Exclusión: pacientes sin buen seguimiento postquirúrgico y con paladar hendido sin reparación quirúrgica. Los datos fueron obtenidos del sistema AS400, el análisis se realizó mediante el programa estadístico International Business Machines Statistical Package for the Social Sciences. RESULTADOS. El uso de ortopedia prequirúrgica (OR: 0,014; p<0,000) y la alimentación con leche materna (OR: 0,033; p<0,003) fueron factores protectores. DISCUSIÓN. La ortopedia prequirúrgica fue la mejor opción de moldeamiento en pacientes con hendiduras amplias para la aproximación de los segmentos óseos hendidos, como factor protector significativo se encontró a la lactancia materna exclusiva dato que coincide con el estudio de López YD., donde mencionó que produjo mayor estimulación para la fusión de las crestas palatinas a pesar de que no fue estadísticamente significativa. CONCLUSION. Los factores asociados al desarrollo de fístula palatina estadísticamente significativos fueron el uso de ortopedia prequirúrgica y la alimentación con leche materna, catalogados como protectores.
INTRODUCTION. Palatal fistula is the persistence of abnormal communication between the nasal and oral cavity post palatoplasty, it Ìs the frequent complication with: high morbidity, feeding problems, inappropriate articulation of words, halitosis and psychosocial problems such as low self-esteem and social rejection. OBJECTIVE. Determine the factors associated with the development of palatal fistula. MATERIALS AND METHODS. Observational, analytical case-control study. From a population of 334 Clinical Histories, a sample of 89 was taken in the Plastic and Reconstructive Unit of the Carlos Andrade Marín Specialty Hospital from january 2010 to july 2019. Inclusion criteria: data from patients with cleft palate repaired by palatoplasty. Exclusion Criteria: patients without good postsurgical follow-up and with a cleft palate without surgical repair. The data were obtained from the AS400 system, the analysis was performed using the International Business Machines Statistical Package for the Social Sciences statistical program. RESULTS. The use of presurgical orthopedics (OR: 0,014; p<0,000) and feeding with breast milk (OR: 0,033; p<0,003) were protective factors. DISCUSSION. Presurgical orthopedics was the best molding option in patients with wide clefts for the approximation of the cleft bone segments, as a significant protective factor, exclusive breastfeeding was found, data that coincides with the study by López YD., where he mentioned that it produced greater stimulation for palatine ridge fusion although it was not statistically significant. CONCLUSION. Statistically significant factors associated with the development of palatal fistula were the use of pre-surgical orthopedics and feeding with breast milk, classified as protective.
Assuntos
Humanos , Masculino , Feminino , Lactente , Palato , Palato Mole , Fístula Bucal , Fenda Labial , Fissura Palatina , Palato Duro , Ortopedia , Obturadores Palatinos , Estudos de Casos e Controles , Odontopediatria , Boca , Cavidade NasalRESUMO
The presence of renal dysfunction is not unusual in patients with pulmonary or cardiac dysfunction who require rescue with extracorporeal membrane oxygenation (ECMO). The complexity, implicit in the implementation of both techniques, can be overwhelming. This review aims to explain the most important aspects of continuous renal replacement therapy in a patient with extracorporeal support.
Assuntos
Injúria Renal Aguda/terapia , Terapia Combinada/métodos , Oxigenação por Membrana Extracorpórea/métodos , Terapia de Substituição Renal/instrumentação , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/mortalidade , Chile/epidemiologia , Oxigenação por Membrana Extracorpórea/classificação , Humanos , Terapia de Substituição Renal/métodos , Fatores de Risco , Taxa de SobrevidaRESUMO
The presence of renal dysfunction is not unusual in patients with pulmonary or cardiac dysfunction who require rescue with extracorporeal membrane oxygenation (ECMO). The complexity, implicit in the implementation of both techniques, can be overwhelming. This review aims to explain the most important aspects of continuous renal replacement therapy in a patient with extracorporeal support.
Assuntos
Humanos , Oxigenação por Membrana Extracorpórea/métodos , Terapia de Substituição Renal/instrumentação , Terapia Combinada/métodos , Injúria Renal Aguda/terapia , Oxigenação por Membrana Extracorpórea/classificação , Chile/epidemiologia , Taxa de Sobrevida , Fatores de Risco , Terapia de Substituição Renal/métodos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/mortalidadeAssuntos
Anticoagulantes/sangue , Oxigenação por Membrana Extracorpórea , Hirudinas/sangue , Fragmentos de Peptídeos/sangue , Adolescente , Adulto , Anticoagulantes/administração & dosagem , Criança , Estudos de Viabilidade , Feminino , Heparina/efeitos adversos , Hirudinas/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Fragmentos de Peptídeos/administração & dosagem , Contagem de Plaquetas , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/sangue , Adulto JovemRESUMO
Background: Extracorporeal membrane oxygenation (ECMO) is used with increasing frequency in patients with respiratory and cardiac failure. The achievement of an adequate anticoagulation is critical to avoid patient and circuit complications. Aim: To assess the feasibility and safety of anticoagulation with bivalirudin, as an alternative to unfractionated heparin (UFH), in patient with ECMO. Material and Methods: Observational study, which included all patients receiving anticoagulation with bivalirudin during ECMO, according to a standardized protocol, between august 2015 to May 2016. Results: Bivalirudin was used in 13 out 70 patients connected to ECMO. Ten procedures were for cardiac support and three for respiratory support. Mortality was 43%. ECMO lasted 31 ± 31 days. The time of UFH use before changing to bivalirudin was 7 ± 7 days. The reasons to change to bivalirudin were inadequate levels of partial thromboplastin time (PTT) in nine patients, and heparin induced thrombocytopenia (HIT) in four patients. The time of bivalirudin use was 24 ± 33 days. Per patient, a mean of 2.7 ± 4 oxygenators were changed. These had a useful life of 11.4 and 19.1 days during UFH and bivalirudin use, respectively. The mean bivalirudin dose was 0.08 ± 0.04 mg/kg/h. There was no significant bleeding, thrombosis or circuit obstruction during its use. PTT levels (p < 0.01) and platelet count (p < 0.01) increased significantly after the start of bivalirudin use in patients with UHF resistance and HIT, respectively. Conclusions: Bivalirudin was a safe and efficient drug for anticoagulation during ECMO. It is important to have an alternative drug for anticoagulation in ECMO patients.
Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Fragmentos de Peptídeos/sangue , Oxigenação por Membrana Extracorpórea , Hirudinas/sangue , Anticoagulantes/sangue , Tempo de Tromboplastina Parcial , Fragmentos de Peptídeos/administração & dosagem , Contagem de Plaquetas , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/sangue , Heparina/efeitos adversos , Estudos de Viabilidade , Hirudinas/administração & dosagem , Anticoagulantes/administração & dosagemRESUMO
We studied prospectively the perioperative changes of renal function in nine children undergoing cardiac surgery with cardiopulmonary bypass (CPB). Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured with inulin and (131)I-hippuran clearances before CPB, during hypo and normothermic CPB, following sternal closure and 1 h postoperatively. Urinary alpha glutathione S-transferase (alpha GS-T) was measured pre- and postoperatively as a marker for tubular cellular damage. Plasma and urine creatinine and electrolytes were measured. Free water, osmolal and creatinine clearances, as well as fractional excretion of sodium (FeNa) and potassium transtubular gradient (TTKG) were calculated. GFR was normal before and after surgery. ERPF was low before and after surgery; it increased significantly immediately after CPB. Filtration fraction (FF) was abnormally elevated before and after surgery; however, a significant decrease during normothermic CPB and sternal closure was found. Alpha GS-T presented a moderate, but nonsignificant increase postoperatively. FeNa also increased in this period, but not significantly. Creatinine, osmolal, free water clearances, as well as TTKG, were normal in all patients pre- and postoperatively. We conclude that there is no evidence of clinically significant deterioration of renal function in children undergoing repair of cardiac lesions under CPB. Minor increases of alpha GS-T in urine postoperatively did not confirm cellular tubular damage. There was no tubular dysfunction at that time.
Assuntos
Ponte Cardiopulmonar , Túbulos Renais/patologia , Túbulos Renais/fisiologia , Creatinina/urina , Feminino , Taxa de Filtração Glomerular/fisiologia , Glutationa Transferase/urina , Humanos , Lactente , Inulina/urina , Ácido Iodoipúrico/metabolismo , Isoenzimas/urina , Testes de Função Renal , Masculino , Estudos Prospectivos , Fluxo Plasmático Renal/fisiologiaRESUMO
Extracorporeal membrane oxygenation (ECMO) improves survival in neonatal and pediatric patients with reversible severe respiratory or cardiac failure, in whom intensive treatment fails. Since 1999, a multidisciplinary team is trained to form the first neonatal-pediatric ECMO center in Chile, according to the norms of the Extracorporeal Life Support Organization (ELSO). During 2003 the first three patients were admitted to the program: a male newborn with pulmonary hypertension, a 38 days old female operated for a total anomalous pulmonary venous connection and a 3 months old male with a severe pneumonia caused by respiratory syncytial virus. They remained in ECMO for five, seven and nine days respectively and all survived to the procedure. No neurological complications were observed after one and a half year of follow up. This consolidates the first national neonatal-pediatric ECMO program, associated to ELSO. Up to date, twelve patients have been admitted to the program.
Assuntos
Oxigenação por Membrana Extracorpórea/normas , Insuficiência Cardíaca/terapia , Hipertensão Pulmonar/terapia , Terapia Intensiva Neonatal/normas , Insuficiência Respiratória/terapia , Chile , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/normas , Masculino , Avaliação de Programas e Projetos de SaúdeRESUMO
Introducción: Recientemente se ha descrito una técnica de perfusión cerebral regional (PCR) que permitiría suprimir o al menos acortar el tiempo de paro circulatorio con hipotemia profunda (PCHP). Nuestro objetivo es comunicar la técnica de PCR empleada en dos entidades clínicas diferentes. Pacientes y métodos: Dos recién nacidos portadores de hipoplasia de corazón izquierdo e interrupción del arco aórtico, respectivamente, fueron sometidos a reparación completa con técnica de PCR, perfundiendo el cerebro a través de un tubo protésico implantado en la arteria innominada, con utilización de circulación extracorpórea e hipotemia profunda. Resultados: En ambos pudo hacerse una corrección muy satisfactoria y la PCR no agregó dificultad al procedimiento, acortándose ostensiblemente el tiempo de PCHP. Los dos pacientes fueron dados de alta sin evidencias de déficit neurológico. Conclusión: La PCR es un método reproducible, que permite acortar o suprimir la necesidad de PCHP en pacientes sometidos a reconstrucción del arco aórtico
Assuntos
Humanos , Masculino , Recém-Nascido , Aorta Torácica/cirurgia , Quimioterapia do Câncer por Perfusão Regional , Síndrome do Coração Esquerdo Hipoplásico , Circulação Extracorpórea , Hipotermia , Parada Cardíaca/cirurgiaRESUMO
El cálculo habitual de resistencia vascular sistémica (SVR) asume que la circulación se comporta como una resistencia, o sea, que relaciona en forma lineal los valores de presión y flujo medios. Por analogía con la ley de Ohm se utiliza la ecuación SVR=(PAM-PVC)/DC, es decir, la caída de presión entre los territorios arterial y venoso dividida por el débito cardíaco. Esta ecuación es usada universalmente en clínica y en investigaciones fisiológicas, aunque debiera ser obvio que es una sobre símplícación. La definición matemática de resistencia es la pendiente de la función presión/flujo, la que resulta difícil de determinar en pacientes. Para establecer si la ecuación SVR=(PAM-PVC)/DC es apropiada, determinamos experimentalmente la relación presión/flujo en 30 pacientes bajo circulación extracorpórea. La relación encontrada no correspondió a la ecuación arríba citada, ya que la presión a flujo cero (P0) resultó en todos los pacientes significativamente mayor que PVC. La pendiente de la relación presíón/flujo determinada experimentalmente, o sea la resistencia propiamente tal corresponde en realidad a la ecuación R=(PAM P0)/DC. Usando esta fórmula se obtienen valores de resistencia menores que usando la ecuación habitual, y no se confirma que la resistencia sea inversamente proporcional al débito cardíaco, como ha sido publicado