RESUMO
BACKGROUNDS: In children with sepsis, circulatory shock and multi-organ failure remain major contributors to mortality. Prolonged capillary refill time (PCRT) is a clinical tool associated with disease severity and tissue hypoperfusion. Microcirculation assessment with videomicroscopy represents a promising candidate for assessing and improving hemodynamic management strategies in children with sepsis. Particularly when there is loss of coherence between the macro and microcirculation (hemodynamic incoherence). We sought to evaluate the association between PCRT and microcirculation changes in sepsis. METHODS: This was a prospective cohort study in children hospitalized with sepsis. Microcirculation was measured using sublingual video microscopy (capillary density and flow and perfused boundary region [PBR]-a parameter inversely proportional to vascular endothelial glycocalyx thickness), phalangeal tissue perfusion, and endothelial activation and glycocalyx injury biomarkers. The primary outcome was the association between PCRT and microcirculation changes. RESULTS: A total of 132 children with sepsis were included, with a median age of two years (IQR 0.6-12.2). PCRT was associated with increased glycocalyx degradation (PBR 2.21 vs. 2.08 microns; aOR 2.65, 95% CI 1.09-6.34; p = 0.02) and fewer 4-6 micron capillaries recruited (p = 0.03), with no changes in the percentage of capillary blood volume (p = 0.13). Patients with hemodynamic incoherence had more PBR abnormalities (78.4% vs. 60.8%; aOR 2.58, 95% CI 1.06-6.29; p = 0.03) and the persistence of these abnormalities after six hours was associated with higher mortality (16.5% vs. 6.1%; p < 0.01). Children with an elevated arterio-venous CO2 difference (DCO2) had an abnormal PBR (aOR 1.13, 95% CI 1.01-1.26; p = 0.03) and a lower density of small capillaries (p < 0.05). Prolonged capillary refill time predicted an abnormal PBR (AUROC 0.81, 95% CI 0.64-0.98; p = 0.03) and relative percentage of blood in the capillaries (AUROC 0.82, 95% CI 0.58-1.00; p = 0.03) on admission. A normal CRT at 24 h predicted a shorter hospital stay (aOR 0.96, 95% CI 0.94-0.99; p < 0.05). CONCLUSIONS: We found an association between PCRT and microcirculation changes in children with sepsis. These patients had fewer small capillaries recruited and more endothelial glycocalyx degradation. This leads to nonperfused capillaries, affecting oxygen delivery to the tissues. These disorders were associated with hemodynamic incoherence and worse clinical outcomes when the CRT continued to be abnormal 24 h after admission.
Assuntos
Sepse , Criança , Humanos , Lactente , Pré-Escolar , Microcirculação/fisiologia , Estudos Prospectivos , Capilares/metabolismo , Biomarcadores/metabolismoRESUMO
Fluid resuscitation with crystalloids has been used in humans for more than 100 years. In patients with trauma, sepsis or shock of any etiology, they can help modify the clinical course of the illness. However, these solutions are medications which are not side-effect free. Recently, they have been questioned in terms of quantity (fluid overload) and their composition. The most frequently used crystalloids, both in high and low-income countries, are 0.9% normal saline (NS) and Ringer's lactate. The first descriptions of the use of sodium and water solutions in humans date from the cholera epidemic which spread throughout Europe in 1831. The composition of the fluids used by medical pioneers at that time differs greatly from the 0.9% NS used routinely today. The term "physiological solution" referred to fluids which did not cause red blood cell hemolysis in amphibians in in vitro studies years later. 0.9% NS has an acid pH, a more than 40% higher chloride concentration than plasma and a strong ion difference of zero, leading many researchers to consider it an unbalanced solution. In many observational studies and clinical trials, this 0.9% NS composition has been associated with multiple microcirculation and immune response complications, acute kidney injury, and worse clinical outcomes. Ringer's lactate has less sodium than plasma, as well as other electrolytes which can cause problems in patients with traumatic brain injury. This review provides a brief summary of the most important historical aspects of the origin of the most frequently used intravenous crystalloids today.
RESUMO
BACKGROUND: A main factor contributing to insufficient glycemic control, during basal/bolus insulin therapy, is poor self-management bolus. Insulin bolus administration frequency is strongly associated with glycated hemoglobin (A1c) in Type 1 Diabetes (T1D). In the present study, we analyzed the performance of two-bolus calculator's software that could be accessible to T1D patients from a Public Health Service to improve glycemic time in range (TIR) and A1c. METHODS: This prospective, controlled, randomized, parallel intervention clinical trial was carried out with 111 T1D participants on basal/bolus therapy [multiple daily insulin injections (MDI) or subcutaneous infusion pump (CSII)] with basal A1c ≥ 8.5% for 24 weeks. Patients were divided into 3 groups: 2 interventions: COMBO® (bolus calculator) and GLIC (mobile application) and 1 control (CSII group). Anthropometrics and metabolic variables were assessed on basal, 3 and 6 months of follow-up. RESULTS: TIR was increased in 9.42% in COMBO group (29 ± 12% to 38.9 ± 12.7%; p < 0.001) in 8.39% in the GLIC® group (28 ± 15% to 36.6 ± 15.1%; p < 0.001) while remained stable in CSII group (40 ± 11% to 39.3 ± 10.3%). A1c decrease in 1.08% (p < 0.001), 0.64% (p < 0.001) and 0.38% (p = 0.01) at 6 months in relation to basal in the COMBO, GLIC and CSII respectively. Daily basal insulin dose was reduced by 8.8% (p = 0.01) in the COMBO group. CONCLUSION: The COMBO and a mobile applicative (GLIC) bolus calculator had a similar and a good performance to optimize the intensive insulin treatment of T1D in the public health system with increase in the TIR and reduction in A1C without increase hypoglycemia prevalence.
RESUMO
The effect of different bolus sizes on food breakdown has been studied in adults, but not in children. The objective of this study was to study median particle size (MPS) and other parameters of masticatory function at swallowing threshold (ST) in 8-10-year-old-children with two different bolus sizes. A randomized crossover trial was undertaken in 89 eight to ten-year-old children. The study was performed with informed consent and ethical approval. The artificial test food used was made of a condensation silicone (Optosil Comfort) following a standardized protocol. Two bolus sizes (three or four quarters of a 20-mm diameter, 5-mm thick tablet) were randomized to avoid an order effect and tested in different sessions. Variables were: MPS (X50 ) at ST, number of cycles until ST, sequence and cycle duration as well as cycles/g. Comparisons were performed with paired t and Wilcoxon tests, regressions and correlations were run. Cutoff for statistical significance was .05. Statistically significant differences were found for all variables; X50 (2.5 ± 0.8 vs. 2.8 ± 0.7 mm, p < .001), cycles until ST (38 vs. 40, p = .022), sequence (25 vs. 27 s, p = .003), and cycle duration (650 vs. 683 ms, p = .015) and cycles/g (27 vs. 21 cycles/g, p < .001), three or four quarters, respectively. In conclusion, in children, as in adults, chewing on a bigger bolus size leads to a larger MPS (X50 ) at ST. When chewing on a larger bolus the number of cycles increases, but not enough to swallow the same particle size since the number of cycles/g is less with a bigger bolus size.
Assuntos
Deglutição , Mastigação , Adulto , Criança , Alimentos , Humanos , Tamanho da Partícula , ComprimidosRESUMO
Objective: The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working in Latin American countries. The experts were organized into 10 nominal groups, each coordinated by a member. Methods: A formal consensus was formed based on the modified Delphi method, combining the opinions of nominal groups of experts with the interpretation of available scientific evidence, in a systematic process of consolidating a body of recommendations. The systematic search was performed by a specialized librarian and included specific algorithms for the Cochrane Specialized Register, PubMed, Lilacs, and Scopus, as well as for OpenGrey databases for grey literature. The GRADEpro GDT guide was used to classify each of the selected articles. Special emphasis was placed on search engines that included original research conducted in LMICs. Studies in English, Spanish, and Portuguese were covered. Through virtual meetings held between February 2020 and February 2021, the entire group of experts reviewed the recommendations and suggestions. Result: At the end of the 12 months of work, the consensus provided 62 recommendations for the diagnosis and treatment of pediatric sepsis in LMICs. Overall, 60 were strong recommendations, although 56 of these had a low level of evidence. Conclusions: These are the first consensus recommendations for the diagnosis and management of pediatric sepsis focused on LMICs, more specifically in Latin American countries. The consensus shows that, in these regions, where the burden of pediatric sepsis is greater than in high-income countries, there is little high-level evidence. Despite the limitations, this consensus is an important step forward for the diagnosis and treatment of pediatric sepsis in Latin America.
Assuntos
Sepse , Criança , Consenso , Cuidados Críticos/métodos , Humanos , América Latina , Sepse/diagnóstico , Sepse/terapiaRESUMO
The horn fly, Haematobia irritans, is a bovine ectoparasite that causes large losses to cattle breeders, through lower meat and milk production and hide damage. Currently, the control of this parasite is mainly through chemicals. However, the indiscriminate use of these substances generates resistance. Pyriproxyfen belongs to an insect growth disruptors class with mechanisms of action for the control of immature forms of the insect. The aim of this study was to investigate the potential of pyriproxyfen administered orally to cattle for the control of the horn fly. In vitro bioassays were carried out by evaluating the number of adults emerged from 30 eggs per replicate, in triplicate, added in a substrate (fresh cattle feces) spiked with pyriproxyfen solutions in the concentration range of 2-130 ppb (ng.g-1). Probit analysis estimated LC50 value of 7.89 ppb and LC90 value of 70.08 ppb. The doses used in the in vivo evaluation were established based on the LC90 values and the anatomical and physiological aspects of the bovine digestive tract. Capsules containing pyriproxyfen at doses of 2.5 mg (G2.5) and 40 mg (G40) were produced and administered orally by bolus applicator for 12 days. The efficacy of pyriproxyfen against the immature forms of H. irritans was determined by incubating eggs in vitro in the feces collected on days 0, +3, +6, +10 and +13. Quantification of pyriproxyfen in feces was performed by UPLC-MS/MS, finding concentrations ranging from 13.4 to 22.6 ppb for G2.5 and between 268.5 to 509.0 ppb for G40. Pyriproxyfen administered orally is eliminated in the active form in the fecal mass and at a dose of 40 mg.day-1 (0.1 mg/kg/day) generates fecal concentrations able to produce 100 % prevention of adults emergence of H. irritans.
Assuntos
Muscidae , Espectrometria de Massas em Tandem , Animais , Bovinos , Cromatografia Líquida/veterinária , Óvulo , Piridinas , Espectrometria de Massas em Tandem/veterináriaRESUMO
BACKGROUND AND AIMS: Few studies have reported on the use of continuous glucose monitoring (CGM) during the Covid-19 pandemic. We aimed to examine glycemic control metrics using flash glucose monitoring during insulin treatment and the clinical outcome in hospitalized patients with COVID-19. METHODS: Prospective, single-center cohort of adult patients diagnosed with type 2 diabetes or hyperglycemia and COVID-19 infection treated with basal bolus insulin regimen. Glycemic control was assessed with the use of intermittent Freestyle Libre flash glucose monitoring during the hospital stay. Outcome of interest were time in range [TIR], time above [TAR] and below [TBR] range, glycemic variability [coefficient of variation [% CV]), and differences in a composite of complications including ICU admission, acute respiratory distress syndrome (ARDS) and acute kidney injury. RESULTS: A total of 60 patients were included (44 known diabetes and 16 new onset hyperglycemia). In total 190,080 data points of CGM were available, of which 72.5% of values were within the target area [TIR (70-180 mg/dL)], 22% TAR (>180 mg/dL), and 3% were TBR (<70 mg/dL). During treatment, the coefficient of variation (% CV) was 30%. There were no association with TIR, but patients with TAR >180 mg/dl had higher rates of a composite of complications (22.5% vs 16%, p = 0.04). CONCLUSIONS: Basal bolus insulin regimen was safe and effective in achieving inpatient glycemic control in most patients with COVID-19. The association between TAR and complications indicates the need for improved inpatient glycemic control in hospitalized patients with COVID-19.
Assuntos
Injúria Renal Aguda/epidemiologia , Glicemia/metabolismo , COVID-19/metabolismo , Diabetes Mellitus Tipo 2/metabolismo , Hiperglicemia/metabolismo , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Síndrome do Desconforto Respiratório/epidemiologia , Idoso , COVID-19/complicações , Estudos de Coortes , Colômbia/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Hemoglobinas Glicadas/metabolismo , Controle Glicêmico , Humanos , Hiperglicemia/tratamento farmacológico , Hiperglicemia/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Projetos Piloto , Testes Imediatos , Estudos Prospectivos , SARS-CoV-2RESUMO
INTRODUCTION: Continuous glucose monitoring (CGM) is a better tool to detect hyper and hypoglycemia than capillary point of care in insulin-treated patients during hospitalization. We evaluated the incidence of hypoglycemia in patients with type 2 diabetes (T2D) treated with basal bolus insulin regimen using CGM and factors associated with hypoglycemia. METHODS: Post hoc analysis of a prospective cohort study. Hypoglycemia was documented in terms of incidence rate and percentage of time <54 mg/dL (3.0 mmol/L) and <70 mg/dL (3.9 mmol/L). Factors evaluated included glycemic variability analyzed during the first 6 days of basal bolus therapy. RESULTS: A total of 34 hospitalized patients with T2D in general ward were included, with admission A1c of 9.26 ± 2.62% (76.8 ± 13 mmol/mol) and mean blood glucose of 254 ± 153 mg/dL. There were two events of hypoglycemia below 54 mg/dL (3.0 mmol/L) and 11 events below 70 mg/dL (3.9 mmol/L) with an incidence of hypoglycemic events of 0.059 and 0.323 per patient, respectively. From second to fifth day of treatment the percentage of time in range (140-180 mg/dL, 7.8-10.0 mmol/L) increased from 72.1% to 89.4%. Factors related to hypoglycemic events <70 mg/dL (3.9 mmol/L) were admission mean glucose (IRR 0.86, 95% CI 0.79, 0.95, P < .01), glycemic variability measured as CV (IRR 3.12, 95% CI 1.33, 7.61, P < .01) and SD, and duration of stay. CONCLUSIONS: Basal bolus insulin regimen is effective and the overall incidence of hypoglycemia detected by CGM is low in hospitalized patients with T2D. Increased glycemic variability as well as the decrease in mean glucose were associated with events <70 mg/dL (3.9 mmol/L).
Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Hipoglicemia/epidemiologia , Insulina/administração & dosagem , Idoso , Glicemia/análise , Glicemia/efeitos dos fármacos , Glicemia/metabolismo , Automonitorização da Glicemia , Estudos de Coortes , Colômbia/epidemiologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Hipoglicemia/induzido quimicamente , Incidência , Masculino , Pessoa de Meia-Idade , Quartos de Pacientes/estatística & dados numéricos , Fatores de RiscoRESUMO
Aims: To monitor the effect of using long-acting Zn boluses on the Zn status of a group of South American camelids, using measurements of concentrations of Zn in faeces and serum. Methods: As part of a facial eczema (FE) prevention programme, 15 camelids were treated with long-acting Zn boluses designed for preventing FE in sheep. Based on bodyweight, 13 alpacas (Vicugna pacos) received two boluses (26.4â g Zn/bolus) and two llamas (Lama glama) received three boluses. In order to monitor Zn status, measurements were made of concentrations of Zn in serum and faeces immediately prior to bolus treatment (Week 0) and 4, 6, 8 and 10 weeks later. Gamma glutamyl transferase (GGT) activity in serum was measured at Weeks 0 and 8. Results: Two alpacas regurgitated the boluses; in one case the animal was quickly re-treated but this was not possible in the second animal. Mean concentrations of Zn in faeces were higher at all time points compared to Week 0 (p < 0.001). Peak concentrations were measured at Week 8, and concentrations >120â mg/kg fresh weight (FW), suggested as being protective in calves, were only measured in all (13/13) treated camelids at Week 6. Mean concentrations of Zn in serum differed between weeks of sampling but changes were not consistent, and concentrations did not exceed 18â µmol/L following treatment. There was no evidence of a natural sporidesmin challenge during the study period and activity of GGT in serum of all animals was <45â IU/L. Conclusions: Treatment with Zn boluses significantly increased concentrations of Zn in faeces but not in serum, but peak concentrations in faeces were only detected 8 weeks after treatment. Clinical Relevance: The delay in achieving concentrations of Zn in faeces which were associated with protection against FE in calves, combined with the difficulties of administering boluses to camelids, means that we do not believe that Zn boluses should be used as the primary method for preventing FE in camelids. We recommend that FE prevention in camelids should focus on minimising spore production in pasture through the use of fungicides, grazing management and alternative forages, with boluses only used when it is thought that these methods are unlikely to provide sufficient protection against FE. Such use should always be under the guidance of a veterinarian and monitoring of serum GGT activity should be used to ensure that FE control is being achieved.
Assuntos
Camelídeos Americanos , Zinco/análise , Animais , Camelídeos Americanos/sangue , Eczema , Fezes/química , América do Sul , Zinco/administração & dosagem , Zinco/sangueRESUMO
Dissociative anesthesia results in stressful and long recovery periods in monkeys and use of injectable anesthetics in medical research has to be refined. Propofol has promoted more pleasure wake up from anesthesia. The objectives of this study were to investigate the use of intravenous anesthetic propofol, establishing the required infusion rate to maintain surgical anesthetic level and comparing it to tiletamine-zolazepam anesthesia in Sapajus apella. Eight healthy capuchin monkeys, premedicated with midazolam and meperidine, were anesthetized with propofol (PRO) or tiletamine-zolazepam (TZ) during 60 minutes. Propofol was infused continually and rate was titrated to effect and tiletamine-zolazepam was given at 5mg/kg IV bolus initially and repeated at 2.5mg/kg IV bolus as required. Cardiopulmonary parameters, arterial blood gases, cortisol, lactate and quality and times to recovery were determined. Recovery quality was superior in PRO. Ventral recumbency (PRO = 43.0±21.4 vs TZ = 219.3±139.7 min) and normal ambulation (PRO = 93±27.1 vs TZ = 493.7±47.8 min) were faster in PRO (p<0.05). Cardiopulmonary effects did not have marked differences between groups. Median for induction doses of propofol was 5.9mg/kg, varying from 4.7 to 6.7mg/kg, Mean infusion rate was 0.37±0.11mg/kg/min, varying during the one-hour period. In TZ, two animals required three and five extra doses. Compared to tiletamine-zolazepam, minor post-anesthetic adverse events should be expected with propofol anesthesia due to the faster and superior anesthetic recovery.(AU)
A anestesia dissociativa em primatas resulta em recuperação anestésica lenta e estressante, e, portanto, o uso de anestesia injetável em pesquisas médicas precisa ser refinado. Por outro lado, o propofol promove recuperação mais suave. Os objetivos desse estudo foram investigar o uso do anestésico intravenoso propofol, estabelecer a taxa de infusão contínua necessária para manter anestesia cirúrgica, e comparar tal técnica com a dissociativa tiletamina-zolazepam em Sapajus apella. Oito macacos-prego saudáveis foram pré-medicados com midazolam e meperidina, e posteriormente anestesiados com propofol (PRO) ou tiletamina-zolazepam (TZ) durante 60 minutos. O propofol foi administrado em infusão contínua, e a taxa foi titulada ao efeito, já a tiletamina-zolazepam foi administrada em 5mg/kg IV como bolus inicial, e repiques de 2,5mg/kg IV conforme necessário. Os parâmetros cardiopulmonares, hemogasometria arterial, cortisol, e lactato, além da qualidade e duração da recuperação anestésica foram determinados. A qualidade da recuperação anestésica foi superior em PRO. O tempo para atingir decúbito ventral (PRO = 43,0±21,4 vs TZ = 219,3±139,7 min) e ambulação normal (PRO = 93±27,1 vs TZ = 493,7±47,8 min) foram mais rápidos em PRO (p<0,05). As variáveis cardiopulmonares não diferiram entre os grupos. A mediana para dose de indução com propofol foi de 5,9mg/kg, variando de 4,7 a 6,7mg/kg. A taxa de infusão contínua média de propofol foi de 0,37±0,11mg/kg/min, variando ao longo dos 60 minutos. Em TZ, dois animais necessitaram de três e cinco repiques. Comparado à tiletamina-zolazepam, menos efeitos adversos pós-anestésicos devem ser esperados com o propofol, devido à recuperação mais suave e rápida.(AU)