OBJECTIVES: To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS: This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS: Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS: In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min.

FUNDAMENTO: Hiperglicemia na fase aguda do infarto do miocárdio é importante fator prognóstico. Entretanto, sua fisiopatologia não está completamente elucidada. OBJETIVO: Analisar simultaneamente correlação entre hiperglicemia e marcadores bioquímicos relacionados ao estresse,metabolismo glicídico e lipídico, coagulação, inflamação e necrose miocárdica. MÉTODOS: Oitenta pacientes com infarto agudo do miocárdio foram incluídos prospectivamente. Os parâmetros analisados foram: glicose, hormônios do estresse (cortisol e norepinefrina), fatores do metabolismo glicídico [hemoglobina glicada (HbA1c), insulina], lipoproteínas (colesterol total, LDL, HDL, LDL eletronegativa minimamente modificada e adiponectina), glicerídeos (triglicérides, VLDL e ácido graxo), fatores da coagulação (fator VII, fibrinogênio,inibidor do ativador do plasminogênio-1), inflamação (proteína C reativa ultrassensível) e necrose miocárdica (CK-MB e troponina). Variáveis contínuas foram convertidas em graus de pertinência por intermédio de lógica fuzzy. RESULTADOS: Houve correlação significativa entre hiperglicemia e metabolismo glicídico (p < 0,001), lipoproteínas (p = 0,03) e fatores de necrose (p = 0,03). Na análise multivariada, somente metabolismo glicídico (OR = 4,3; IC = 2,1-68,9 e p < 0,001) e necrose miocárdica (OR = 22,5; IC = 2-253 e p = 0,012) mantiveram correlação independente e significativa.Para análise da influência da história de diabetes mellitus , modelo de regressão, incluindo somente pacientes sem diabetes mellitus foi desenvolvido, e os resultados não alteraram. Finalmente, no modelo ajustado para idade, sexo e variáveis clínicas(história de diabetes mellitus, hipertensão arterial e dislipidemia), três variáveis mantiveram associação significativa e independente com hiperglicemia: metabolismo glicídico (OR = 24,1; IC = 4,8-122,1 e p < 0,001) necrose miocárdica (OR = 21,9; IC = 1,3-360,9 e p = 0,03) e história de DM (OR = 27, IC = 3,7-195,7 e p = 0,001). CONCLUSÃO: Marcadores do metabolismo glicídico e necrose miocárdica foram os melhores preditores de hiperglicemia em pacientes com infarto agudo do miocárdio.

BACKGROUND: Hyperglycemia in the acute phase of myocardial infarction is an important prognostic factor. However, its pathophysiology is not fully understood. OBJECTIVE: To analyze simultaneously the correlation between hyperglycemia and biochemical markers related to stress, glucose and lipid metabolism, coagulation, inflammation, and myocardial necrosis. METHODS Eighty patients with acute myocardial infarction were prospectively included. The following parameters were analyzed: blood glucose; stress hormones (cortisol and norepinephrine); glucose metabolism factors [glycated hemoglobin (HbA1c); insulin]; lipoproteins (total cholesterol, LDL, HDL, minimally modified electronegative LDL, and adiponectin); glycerides (triglycerides, VLDL and fatty acids); coagulation factors (factor VII, fibrinogen, plasminogen activator inhibitor-1); inflammation (high-sensitivity C reactive protein); and myocardial necrosis (CK-MB and troponin). Continuous variables were converted into degrees of relevance using fuzzy logic. RESULTS: Significant correlation was observed between hyperglycemia and glucose metabolism (p < 0.001), lipoproteins (p = 0.03), and necrosis factors (p = 0.03). In the multivariate analysis, only glucose metabolism (OR = 4.3; CI = 2.1-68.9; and p < 0.001) and myocardial necrosis (OR = 22.5; CI = 2-253; and p = 0.012) showed independent and significant correlation. For the analysis of the influence of history of diabetes mellitus, a regression model including only patients without diabetes mellitus was developed, and the results did not change. Finally, in the model adjusted for age, gender, and clinical variables (history of diabetes mellitus, hypertension and dyslipidemia), three variables maintained a significant and independent association with hyperglycemia: glucose metabolism (OR = 24.1; CI = 4.8-122.1; and p < 0.001), myocardial necrosis (OR = 21.9; CI = 1.3-360.9; and p = 0.03), and history of DM (OR = 27; CI = 3.7-195.7; and p = 0.001). CONCLUSION: Glucose metabolism and myocardial necrosis markers were the best predictors of hyperglycemia in patients with acute myocardial infarction.

OBJETIVO: Avaliar a presença de diabetes mellitus e a intolerância à glicose em pacientes internados em unidades de terapia intensiva. MÉTODOS: Foram incluídos pacientes clínicos, em pós-operatório de cirurgias eletivas e de urgência, e excluídos aqueles com história de diabetes mellitus. Para o diagnóstico de alterações prévias da glicemia, utilizou-se a dosagem da hemoglobina glicada (HbA1c) na admissão do paciente, sendo classificado em normal (<5,7%), intolerante à glicose (5,7-6,4%) ou diabético (>6,4%). Durante os 3 primeiros dias da internação, foram avaliados o controle glicêmico e as complicações clínicas. A evolução para óbito foi acompanhada por 28 dias. Para as análises estatísticas, utilizaram-se testes do qui-quadrado, ANOVA, teste t de Student, Kruskall-Wallis ou Mann Whitney. RESULTADOS: Foram incluídos 30 pacientes, 53% do gênero feminino, idade de 53,4±19,7 anos e APACHE II de 13,6±6,6. A maioria dos pacientes foi admitida por sepse grave ou choque séptico, seguido por pós-operatório de cirurgias eletivas, oncológicas, politraumatismo e cirurgia de urgência. Ao classificar esses pacientes segundo a HbA1c, apesar da ausência prévia de história de diabetes mellitus, apenas 13,3% tinham HbA1c normal, 23,3% tinham níveis compatíveis com o diagnóstico de diabetes mellitus e 63,3% eram compatíveis com intolerância à glicose. Houve associação significativa entre o diagnóstico de diabetes mellitus ou intolerância a glicose e o uso de droga vasoativa (p=0,04). CONCLUSÃO: Foi encontrada alta prevalência de diabetes mellitus e intolerância à glicose, sem diagnóstico prévio, em pacientes internados em uma unidade de terapia intensiva geral.

OBJECTIVE: To evaluate the presence of diabetes mellitus and impaired glucose tolerance in intensive care unit inpatients. METHODS: The study included patients in post-surgical care for elective and emergency surgery and excluded those patients with known diabetes mellitus. To diagnose prior serum glucose level disorders, we considered the value of glycated hemoglobin (HbA1c) at the time of admission, classifying the patients as normal (<5.7%), glucose intolerant (5.7-6.4%) or diabetic (>6.4%). During the first 3 days of the patient's hospital stay, glycemic control and clinical complications were assessed. Mortality was monitored for 28 days. For the statistical analyses, chi-square, ANOVA, student's t, Kruskal-Wallis or Mann Whitney tests were used. RESULTS: Thirty patients were included in the present study, 53% of whom were women; the patients had a mean age of 53.4±19.7 years and an APACHE II score of 13.6±6.6. The majority of patients were admitted for severe sepsis or septic shock followed by post-operative care for elective surgery, oncological surgery, multiple traumas and emergency surgery. When classifying these patients according to HbA1c, despite the absence of a prior history of diabetes mellitus, only 13.3% had a normal HbA1c level, 23.3% had levels compatible with the diagnosis of diabetes mellitus and 63.3% had levels compatible with impaired glucose tolerance. We found a significant association between the diagnosis of diabetes mellitus or impaired glucose tolerance and the use of vasoactive drugs (p=0.04). CONCLUSION: A high prevalence of undiagnosed diabetes mellitus and impaired glucose tolerance was observed in inpatients at a general intensive care unit.

INTRODUCTION: Oral β-blockers improve the prognosis of patients with acute myocardial infarction, while atrial fibrillation worsens the prognosis of this population. The reduction of atrial fibrillation incidence in patients treated with β-blockers could at least in part explain the benefits of this drug. OBJECTIVE: To investigate the effect of β-blockers on the incidence of atrial fibrillation in patients with acute myocardial infarction. METHODS: We analyzed 1401 patients with acute myocardial infarction and evaluated the occurrence or absence of atrial fibrillation, the use of oral β-blockers and mortality during the first 24 hours. RESULTS: a) The use of β-blockers was inversely correlated with the presence of atrial fibrillation (ρ = 0.004; OR = 0.54). b) Correlations with mortality were as follows: 31.5% in patients with atrial fibrillation, 9.2% in those without atrial fibrillation (ρ < 0.001; Odds Ratio = 4.52), and 17.5% in patients not treated with β-blockers and 6.7% in those who received the drug (ρ < 0.001; OR = 0.34). c) Adjusted Models: The presence of atrial fibrillation was independently correlated with mortality (OR = 2.48, ρ = 0.002). The use of β-blockers was inversely and independently correlated with mortality (OR = 0.53; ρ = 0.002). The patients who used β-blockers showed a lower risk of atrial fibrillation (OR = 0.59; ρ = 0.029) in the adjusted model. CONCLUSION: The presence of atrial fibrillation and the absence of oral β-blockers increased in-hospital mortality in patients with acute myocardial infarction. Oral β-blockers reduced the incidence of atrial fibrillation, which might be at least partially responsible for the drug's benefit.

OBJETIVO: Analisar os fatores pré-operatórios preditores de mortalidade, em pacientes submetidos à RM nos primeiros 30 dias após infarto agudo do miocárdio (IAM). MÉTODOS: Entre 3/1998 e 7/2002, foram incluídos, consecutiva e prospectivamente, em um banco de dados, 753 pacientes com IAM, sendo que 135 (17,9%) foram submetidos à revascularização miocárdica (RM) isolada e incluídos neste estudo. Estudaram-se os seguintes fatores prognósticos, através de análise multivariada: idade, sexo, diabete, história de IAM, RM ou angioplastia (ATC), localização do IAM, IAM Q, uso de fibrinolítico, intervalo entre o IAM e a cirurgia, presença de complicações no pré-operatório. RESULTADOS: A mortalidade hospitalar global foi de 6,7%, variando de 12,5% nos pacientes portadores de complicações pré-operatórias a 1,4% naqueles sem complicações. Tiveram correlação estatisticamente significante com a mortalidade pós-operatória apenas história prévia de angioplastia (p=0,037) e choque cardiogênico (p=0,002). Em contrapartida, o uso de trombolítico na abordagem inicial do IAM apresentou correlação negativa com a mortalidade (p=0,035). CONCLUSÃO: A RM na fase aguda do IAM é um procedimento que apresenta mortalidade cirúrgica distinta, na dependência da condição clínica pré-operatória do paciente. Dentre os fatores analisados, a presença de choque cardiogênico pré-operatório e história de angioplastia prévia determinaram pior prognóstico neste grupo de pacientes.

OBJECTIVE: To assess preoperative predictors of mortality in patients undergoing coronary artery bypass grafting (CABG) within the first 30 days of acute myocardial infarction (AMI). METHODS: Between March 1998 and July 2002, 753 AMI patients were consecutively and prospectively entered into a database, 135 (17.9%) of whom underwent isolated CABG and were enrolled in this study. The following prognostic factors were assessed by multivariate analysis: age, gender, diabetes, history of previous AMI, CABG or coronary angioplasty (PTCA), anterior infarct location, Q-wave AMI, the use of fibrinolytics, elapsed time from AMI to the procedure, and presence of complications in the preoperative period. RESULTS: Overall in-hospital mortality was 6.7%, ranging from 12.5% in patients with preoperative complications to 1.4% in those with no complications. Only history of previous angioplasty (p = 0.037) and cardiogenic shock (p = 0.002) showed a statistically significant correlation with postoperative mortality. The use of thrombolytics, on the other hand, in the initial management of AMI showed a negative correlation with mortality (p = 0.035). CONCLUSION: CABG in the acute phase of MI is associated with distinct operative mortality, depending on the patient’s preoperative clinical condition. Among those factors analyzed, preoperative cardiogenic shock and history of previous angioplasty were predictive of worse prognosis in this group of patients.

A doença de Behçet pode ser acompanhada de manifestações pulmonares, às vezes letais se não tratadas adequadamente. Descreve-se o caso de um homem de 53 anos com história de episódios de aftas orais e febre havia vários anos, dois quadros febris prolongados nos últimos dois anos, uveíte tratada com corticóide havia 21 meses, hemoptise havia um mês e emagrecimento de 7kg. Ao exame físico apresentava aftas orais, pseudofoliculite e turvação visual. Os estudos radiológicos evidenciaram dilatação aneurismática de artéria pulmonar. Tratado com corticóide, foi feita lobectomia inferior esquerda e o exame anatomopatológico foi compatível com arterite de artéria pulmonar. O paciente foi tratado com clorambucil por oito meses e mantém-se bem, decorridos 18 meses da cirurgia.

Behçet disease has been associated to pulmonary manifestations and may be lethal if not treated correctly. The authors describe a case of a 53 year-old male with aneurysmatic pulmonary artery dilatation, pulmonary hypertension, and hemoptysis. A review is presented about the diagnosis and the medical and surgical treatment of this disease.