Publications by authors named "Joel Avancini Rocha-Filho"

19 Publications

  • Page 1 of 1

Model for establishing a new liver transplantation center through mentorship from a university with transplantation expertise.

PLoS One 2022 30;17(3):e0266361. Epub 2022 Mar 30.

Liver and Digestive Organs Transplantation Division, Gastroenterology Department, Clinical Hospital of São Paulo University - HCFMUSP, São Paulo Faculty of Medicine, Universidade de São Paulo - USP, São Paulo, São Paulo, Brazil.

Background: Setting up new liver transplant (LT) centers is essential for countries with organ shortages. However, good outcomes require experience, because LT learning depends on a high number of surgeries. This study aims to describe how a new center was set up from a partnership between the new center and an experienced one. The step-by-step preparation process, the time needed and the results of the new center are depicted.

Material And Methods: The mentoring process lasted 40 months, in which half of the 52 patients included on the transplant list received LT. After the mentorship, a 22-month period was also analyzed, in which 46 new patients were added to the waiting list and nine were operated on.

Results: The 30-day survival rates during (92.3%) and after (66.7%) the partnership were similar to the other LT centers in the same region, as well as the rates of longer periods. The waiting time on the LT list, the characteristics of the donors and the ischemia times did not differ during or after the mentorship.

Conclusion: The partnership between universities is a suitable way to set up LT centers, achieving good results for the institutions and the patients involved.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266361PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8967004PMC
March 2022

Creatinine-lactate score predicts mortality in non-acetaminophen-induced acute liver failure in patients listed for liver transplantation.

BMC Gastroenterol 2021 Jun 7;21(1):252. Epub 2021 Jun 7.

Laboratorio de Investigaçao Medica 37, Departamento de Gastroenterologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo - HCFMUSP, Sao Paulo, SP, Brazil.

Background: The aim of this study was to analyze prognostic indicators of in-hospital mortality among patients listed for urgent liver transplantation (LT) for non-acetaminophen (APAP)-induced acute liver failure (ALF).

Methods: ALF patients listed for LT according to the King's College Criteria were retrospectively reviewed. Variables were recorded from medical records and electronic databases (HCMED and RedCap).

Results: The study included 100 patients, of which 69 were subject to LT and 31 died while waiting for LT. Patients were 35.5 ± 14.73 years old, and 78% were females. The main etiologies were virus (17%), drug-induced (32%), autoimmune (15%), and indeterminate hepatitis (31%). The prioritization-to-LT time interval was 1.5 days (0-9). The non-LT patients showed higher lactate (8.71 ± 5.36 vs. 4.48 ± 3.33 mmol/L), creatinine (229 ± 207 vs. 137 ± 136 µm/L), MELD (44 ± 8 vs. 38 ± 8), and BiLE scores (15.8 ± 5.5 vs. 10.3 ± 4.1) compared to LT patients (p < 0.05). Multiple logistic regression analysis identified creatinine and lactate as independent prognostic factors, and a creatinine-lactate (CL) score was developed. ROC analysis showed that creatinine, lactate, MELD, BiLE, and CL scores had considerable specificity (71-88%), but only BiLE, lactate, and CL presented high sensitivities (70%, 80%, and 87% respectively). AUCs were 0.696 for creatinine, 0.763 for lactate, 0.697 for MELD, 0.814 for BiLE, and 0.835 for CL.

Conclusions: CL and BiLE scores predict mortality with more accuracy than MELD in patients with ALF during prioritization time. Creatinine and lactate are independent prognostic factors for mortality.
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http://dx.doi.org/10.1186/s12876-021-01830-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185921PMC
June 2021

Perioperative blood transfusion decreases long-term survival in pediatric living donor liver transplantation.

World J Gastroenterol 2021 Mar;27(12):1161-1181

Department of Gastroenterology, Division of Liver and Gastrointestinal Transplant, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo 05402-000, Brazil.

Background: The impact of perioperative blood transfusion on short- and long-term outcomes in pediatric living donor liver transplantation (PLDLT) must still be ascertained, mainly among young children. Clinical and surgical postoperative complications related to perioperative blood transfusion are well described up to three months after adult liver transplantation.

Aim: To determine whether transfusion is associated with early and late postoperative complications and mortality in small patients undergoing PLDLT.

Methods: We evaluated the effects of perioperative transfusion on postoperative complications in recipients up to 20 kg of body weight, submitted to PLDLT. A total of 240 patients were retrospectively allocated into two groups according to postoperative complications: Minor complications ( = 109) and major complications ( = 131). Multiple logistic regression analysis identified the volume of perioperative packed red blood cells (RBC) transfusion as the only independent risk factor for major postoperative complications. The receiver operating characteristic curve was drawn to identify the optimal volume of the perioperative RBC transfusion related to the presence of major postoperative complications, defining a cutoff point of 27.5 mL/kg. Subsequently, patients were reallocated to a low-volume transfusion group (LTr; = 103, RBC ≤ 27.5 mL/kg) and a high-volume transfusion group (HTr; = 137, RBC > 27.5 mL/kg) so that the outcome could be analyzed.

Results: High-volume transfusion was associated with an increased number of major complications and mortality during hospitalization up to a 10-year follow-up period. During a short-term period, the HTr showed an increase in major infectious, cardiovascular, respiratory, and bleeding complications, with a decrease in rejection complications compared to the LTr. Over a long-term period, the HTr showed an increase in major infectious, cardiovascular, respiratory, and minor neoplastic complications, with a decrease in rejection complications. Additionally, Cox hazard regression found that high-volume RBC transfusion increased the mortality risk by 3.031-fold compared to low-volume transfusion. The Kaplan-Meier survival curves of the studied groups were compared using log-rank tests and the analysis showed significantly decreased graft survival, but with no impact in patient survival related to major complications. On the other hand, there was a significant decrease in both graft and patient survival, with high-volume RBC transfusion.

Conclusion: Transfusion of RBC volume higher than 27.5 mL/kg during the perioperative period is associated with a significant increase in short- and long-term postoperative morbidity and mortality after PLDLT.
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http://dx.doi.org/10.3748/wjg.v27.i12.1161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006094PMC
March 2021

Hypertonic saline solution decreases oxidative stress in liver hypothermic ischemia.

Surgery 2021 06 5;169(6):1512-1518. Epub 2021 Mar 5.

Laboratorio de Investigaçao Medica 37, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brasil; Serviço de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Brasil.

Background: Liver ischemia reperfusion injury is still an unsolved problem in liver surgery and transplantation. In this setting, hypothermia is the gold standard method for liver preservation for transplantation. Hypertonic saline solution reduces inflammatory response with better hemodynamic recovery in several situations involving ischemia reperfusion injury. Here, we investigated the effect of hypertonic saline solution in hypothermic liver submitted to ischemia reperfusion injury.

Methods: Fifty male rats were divided into 5 groups: SHAM, WI (animals submitted to 40 minutes of partial warm liver ischemia and reperfusion), HI (animals submitted to 40 minutes hypothermic ischemia), HSPI (animals submitted to hypothermic ischemia and treated with 7.5% hypertonic saline solution preischemia), and HSPR (animals submitted to hypothermic ischemia and treated with hypertonic saline solution previously to liver reperfusion). Four hours after reperfusion, the animals were euthanized to collect liver and blood samples.

Results: Aspartate aminotransferase and alanine aminotransferase, histologic score, and hepatocellular necrosis were significantly decreased in animals submitted to hypothermia compared with the warm ischemia group. Malondialdehyde was significantly decreased in hypothermic groups with a further decrease when hypertonic saline solution was administrated preischemia. Hypothermic groups also showed decreased interleukin-6, interleukin-10, and tumor necrosis factor-α concentrations and better recovery of bicarbonate, base excess, lactate, and glucose blood concentrations. Moreover, hypertonic saline solution preischemia was more effective at controlling serum potassium concentrations.

Conclusion: Hypertonic saline solution before hypothermic hepatic ischemia decreases hepatocellular oxidative stress, cytokine concentrations, and promotes better recovery of acid-base disorders secondary to liver ischemia reperfusion.
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http://dx.doi.org/10.1016/j.surg.2020.12.042DOI Listing
June 2021

Ultrasound-guided peripheral abdominal wall blocks.

Clinics (Sao Paulo) 2021 20;76:e2170. Epub 2021 Jan 20.

Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.

The practice of regional anesthesia is in a state of progressive evolution, mainly due to the advent of ultrasound as an anesthesiologist's instrument. Alternative techniques for postoperative analgesia of abdominal surgeries, such as transversus abdominis plane block, oblique subcostal transversus abdominis plane block, rectus abdominis muscle sheath block, ilioinguinal and iliohypogastric nerve block, and quadratus lumborum plane block, have proven useful, with good analgesic efficacy, especially when neuroaxial techniques (spinal anesthesia or epidural anesthesia) are not possible. This review discusses such blockades in detail, including the anatomical principles, indications, techniques, and potential complications.
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http://dx.doi.org/10.6061/clinics/2021/e2170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798119PMC
April 2021

Sevoflurane Preconditioning plus Postconditioning Decreases Inflammatory Response with Hemodynamic Recovery in Experimental Liver Ischemia Reperfusion.

Gastroenterol Res Pract 2019 7;2019:5758984. Epub 2019 Apr 7.

Department of Gastroenterology, Medical Investigation Laboratory LIM37, Hospital das Clinicas of University of Sao Paulo School of Medicine, Sao Paulo, Brazil.

Objective: The inhalation anesthetic sevoflurane has presented numerous biological activities, including anti-inflammatory properties and protective effects against tissue ischemic injury. This study investigated the metabolic, hemodynamic, and inflammatory effects of sevoflurane pre- and postconditioning for short periods in the rescue of liver ischemia-reperfusion (IR) injury using a rat model.

Materials And Methods: Twenty Wistar rats were divided into four groups: sham group, control ischemia group (partial warm liver ischemia for 45 min followed by 4 h of reperfusion), SPC group (administration of sevoflurane 2.5% for 15 min with 5 min of washout before liver IR), and SPPoC group (administration of sevoflurane 2.5% for 15 min before ischemia and 20 min during reperfusion).

Results: All animals showed a decrease in the mean arterial pressure (MAP) and portal vein blood flow during ischemia. After 4 h of reperfusion, only the SPPoC group had MAP recovery. In both the SPC and SPPoC groups, there was a decrease in the ALT level and an increase in the bicarbonate and potassium serum levels. Only the SPPoC group showed an increase in the arterial blood ionized calcium level and a decrease in the IL-6 level after liver reperfusion. Therefore, this study demonstrated that sevoflurane preconditioning reduces hepatocellular injury and acid-base imbalance in liver ischemia. Furthermore, sevoflurane postconditioning promoted systemic hemodynamic recovery with a decrease in inflammatory response.
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http://dx.doi.org/10.1155/2019/5758984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476030PMC
April 2019

Independent early predictors of mortality in polytrauma patients: a prospective, observational, longitudinal study.

Clinics (Sao Paulo) 2017 Aug;72(8):461-468

Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.

Objectives:: Trauma is an important public health issue and associated with substantial socioeconomic impacts and major adverse clinical outcomes. No single study has previously investigated the predictors of mortality across all stages of care (pre-hospital, emergency room, surgical center and intensive care unit) in a general trauma population. This study was designed to identify early predictors of mortality in severely injured polytrauma patients across all stages of care to provide a better understanding of the physiologic changes and mechanisms by which to improve care in this population.

Methods:: A longitudinal, prospective, observational study was conducted between 2010 and 2013 in São Paulo, Brazil. Patients submitted to high-energy trauma were included. Exclusion criteria were as follows: injury severity score <16, <18 years old or insufficient data. Clinical and laboratory data were collected at four time points: pre-hospital, emergency room, and 3 and 24 hours after hospital admission. The primary outcome assessed was mortality within 30 days. Data were analyzed using tests of association as appropriate, nonparametric analysis of variance and generalized estimating equation analysis (p<0.05). ClinicalTrials.gov: NCT01669577.

Results:: Two hundred patients were included. Independent early predictors of mortality were as follows: arterial hemoglobin oxygen saturation (p<0.001), diastolic blood pressure (p<0.001), lactate level (p<0.001), Glasgow Coma Scale score (p<0.001), infused crystalloid volume (p<0.015) and presence of traumatic brain injury (p<0.001).

Conclusion:: Our results suggest that arterial hemoglobin oxygen saturation, diastolic blood pressure, lactate level, Glasgow Coma Scale, infused crystalloid volume and presence of traumatic brain injury are independent early mortality predictors.
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http://dx.doi.org/10.6061/clinics/2017(08)02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577616PMC
August 2017

PRELIMINARY RESULTS OF TOPICAL HEPATIC HYPOTHERMIA IN A MODEL OF LIVER ISCHEMIA/REPERFUSION INJURY IN RATS.

Arq Gastroenterol 2017 Jul-Sept;54(3):246-249. Epub 2017 Jul 6.

Hospital das Clínicas, Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, Divisão de Cirurgia Digestiva, São Paulo, SP, Brasil.

Background: Ischemia/reperfusion causes organ damage but it is mandatory in hepatic transplantation, trauma and other complex liver surgeries, when Pringle maneuver is applied to minimize bleeding during these procedures. It is well known that liver ischemia/reperfusion leads to microcirculatory disturbance and cellular injury. In this setting hypothermia is known to reduce oxygen demand, lowering intracellular metabolism.

Objective:: To evaluate the effects of hypothermia in liver ischemia/reperfusion injury, using a new model of topic isolated liver hypothermia.

Methods: We used male Wistar rats weighting about 250 grams, kept in ad libitum feeding regime and randomly divided into two groups of nine animals: 1) Normothermic group, rats were submitted to normothermic ischemia of the median and left hepatic lobes, with subsequent resection of right and caudate lobes during liver reperfusion; and 2) Hypothermic group, rats were submitted to liver ischemia under hypothermia at 10°C. Liver ischemia was performed for 45 minutes. The animals were euthanized 48 hours after liver reperfusion for blood and liver tissue sampling.

Results: The transaminases analyses showed a significant decrease of AST and ALT in Hypothermic group (P<0.01) compared to Normothermic group (1403±1234 x 454±213 and 730±680 x 271±211 U/L, respectively). Histology showed severe necrosis in 50% and mild necrosis in 50% of cases in Normothermic group, but severe necrosis in 10% and mild or absent necrosis 90% of the cases in hypothermic group.

Conclusion:: A simplified model of liver ischemia/reperfusion that simulates orthotopic liver autotransplantion was demonstrated. Topical hypothermia of isolated hepatic lobules showed liver protection, being a viable and practical method for any kind of in vivo liver preservation study.
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http://dx.doi.org/10.1590/S0004-2803.201700000-30DOI Listing
November 2017

Does autologous blood transfusion during liver transplantation for hepatocellular carcinoma increase risk of recurrence?

World J Gastrointest Surg 2016 Feb;8(2):161-8

Raphael LC Araujo, Liver Surgery Unit, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, CEP 05403-900, Brazil.

Aim: To analyze outcomes in patients who underwent liver transplantation (LT) for hepatocellular carcinoma (HCC) and received autologous intraoperative blood salvage (IBS).

Methods: Consecutive HCC patients who underwent LT were studied retrospectively and analyzed according to the use of IBS or not. Demographic and surgical data were collected from a departmental prospective maintained database. Statistical analyses were performed using the Fisher's exact test and the Wilcoxon rank sum test to examine covariate differences between patients who underwent IBS and those who did not. Univariate and multivariate Cox regression models were developed to evaluate recurrence and death, and survival probabilities were estimated using the Kaplan-Meier method and compared by the log-rank test.

Results: Between 2002 and 2012, 158 consecutive patients who underwent LT in the same medical center and by the same surgical team were identified. Among these patients, 122 (77.2%) were in the IBS group and 36 (22.8%) in the non-IBS group. The overall survival (OS) and recurrence free survival (RFS) at 5 years were 59.7% and 83.3%, respectively. No differences in OS (P = 0.51) or RFS (P = 0.953) were detected between the IBS and non-IBS groups. On multivariate analysis for OS, degree of tumor differentiation remained as the only independent predictor. Regarding patients who received IBS, no differences were detected in OS or RFS (P = 0.055 and P = 0.512, respectively) according to the volume infused, even when outcomes at 90 d or longer were analyzed separately (P = 0.518 for both outcomes).

Conclusion: No differences in RFS or OS were detected according to IBS use. Trials addressing this question are justified and should be designed to detect small differences in long-term outcomes.
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http://dx.doi.org/10.4240/wjgs.v8.i2.161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4770170PMC
February 2016

NUTRITIONAL SUPPORT FOR FULMINANT HEPATITIS.

Nutr Hosp 2015 Dec 1;32(6):2427-32. Epub 2015 Dec 1.

Hospital das Clínicas from University of Sao Paulo School of Medicine, Discipline of Digestive Surgery (LIM35), Department of Gastroenterology, Sao Paulo, Brazil..

Introduction: fulminant hepatitis (FH) is associated with exacerbated hypercatabolism, hypoglycemia and hyperammonemia that are accompanied by the release of proinflammatory cytokines and catabolic hormones into the systemic circulation worsening patient's clinical condition. Nutritional support is a crucial element for the recovery of these patients.

Objectives: the aim of this review is to update Nutritional Support for Fulminant Hepatitis.

Methods: the review was performed using electronic search on Medline-PubMed using Mesh-terms.

Results And Discussion: there are not many data available on nutritional support to fulminant hepatitis or acute liver failure. Strategies for initial nutritional intervention are focused on the control of the previously described FH metabolic derangements, and should be individualized according to the severity of patient's clinical condition. Energy and protein can be provided in amounts of 25‑40 kcal/kg/day and 0.8-1.2 g/kg/day, respectively. Enteral nutrition therapy is indicated for patients with advancing encephalopathy or for those who cannot be properly fed orally. Euglycemia must be achieved and protein intake can be based on BCAA formulae. Lipids can be administered as energy supplementation with caution. Adequate nutrition therapy can potentially reduce morbidity and mortality of FH patients.
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http://dx.doi.org/10.3305/nh.2015.32.6.9769DOI Listing
December 2015

Effects of terlipressin as early treatment for protection of brain in a model of haemorrhagic shock.

Crit Care 2015 Mar 13;19:107. Epub 2015 Mar 13.

Laboratório de Investigação Médica (LIM-08), Disciplina de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Arnaldo, 455, 2° andar, sala 2120, Cerqueira César, São Paulo, SP, 01246-903, Brazil.

Introduction: We investigated whether treatment with terlipressin during recovery from hypotension due to haemorrhagic shock (HS) is effective in restoring cerebral perfusion pressure (CPP) and brain tissue markers of water balance, oxidative stress and apoptosis.

Methods: In this randomised controlled study, animals undergoing HS (target mean arterial pressure (MAP) 40 mmHg for 30 minutes) were randomised to receive lactated Ringer's solution (LR group; n =14; volume equal to three times the volume bled), terlipressin (TERLI group; n =14; 2-mg bolus), no treatment (HAEMO group; n =12) or sham (n =6). CPP, systemic haemodynamics (thermodilution technique) and blood gas analyses were registered at baseline, shock and 5, 30, 60 (T60), 90 and 120 minutes after treatment (T120). After the animals were killed, brain tissue samples were obtained to measure markers of water balance (aquaporin-4 (AQP4)), Na(+)-K(+)-2Cl(-) co-transporter (NKCC1)), oxidative stress (thiobarbituric acid reactive substances (TBARS) and manganese superoxide dismutase (MnSOD)) and apoptotic damage (Bcl-x and Bax).

Results: Despite the HS-induced decrease in cardiac output (CO) and hyperlactataemia, resuscitation with terlipressin recovered MAP and resulted in restoration of CPP and in cerebral protection expressed by normalisation of AQP4, NKCC1, TBARS and MnSOD expression and Bcl-x/Bax ratio at T60 and T120 compared with sham animals. In the LR group, CO and blood lactate levels were recovered, but the CPP and MAP were significantly decreased and TBARS levels and AQP4, NKCC1 and MnSOD expression and Bcl-x/Bax ratio were significantly increased at T60 and T120 compared with the sham group.

Conclusions: During recovery from HS-induced hypotension, terlipressin was effective in normalising CPP and cerebral markers of water balance, oxidative damage and apoptosis. The role of this pressor agent on brain perfusion in HS requires further investigation.
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http://dx.doi.org/10.1186/s13054-015-0825-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4373118PMC
March 2015

Hypoxia among patients on the liver-transplant waiting list.

Arq Bras Cir Dig 2014 Jan-Mar;27(1):56-8

Department of Gastroenterology, School of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil.

Background: Hepatopulmonary syndrome is formed by a triad of liver disease, intrapulmonary vascular dilatation and changes in blood gases. This condition is present in 4-32% of patients with cirrhosis.

Aim: To analyze the blood gas changes data of patients in liver-transplant waiting list.

Method: Clinical data of 279 patients in liver transplantation waiting list in May 2013 were studied. Overall patient was analyzed by the demographic aspects, laboratorial and image findings on exams that determine lung disease (hypoxemia) in these cirrhotic patients. The mean values and standard deviations were used to examine normally distributed variables.

Results: There was a high prevalence of male patients (68%); the mean age was 51(± 5,89) years, and the predominant reason for listing was hepatitis C cirrhosis. The MELD score mean was 16 ± 5,89, without prioritization or special situation. The most common blood type was O in 129 cases (46%) and the mean of body max index was 25,94 ± 4,58. Regarding arterial blood gas tests was observed 214 patients with PaO2 <90 mmHg, 80 with PaO2 <80 mmHg and 39 with PaO2 <50 mmHg. In relation to O2 saturation, 50 patients had <90%, 33 <80% and 10 <50%.

Conclusion: Was observed a high rate of hypoxemia in patients on waiting list liver transplant. Due to the high severity and morbidity, is suggested better monitoring and therapeutic support to hypoxemic patients on liver transplant waiting list.
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http://dx.doi.org/10.1590/s0102-67202014000100014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4675473PMC
December 2014

Hemostatic resuscitation in traumatic hemorrhagic shock: case report.

Braz J Anesthesiol 2013 Jan 7;63(1):99-102. Epub 2013 Aug 7.

TSA; Associate Professor, FMUSP.

Background And Objectives: The aim of this paper is to report a case in which the damage control resuscitation (DCR) approach was successfully used to promote hemostatic resuscitation in a polytraumatized patient with severe hemorrhagic shock.

Case Report: Female patient, 32 years of age, with severe hemorrhagic shock due to polytrauma with hip fracture, who developed acidosis, coagulopathy, and hypothermia. During fluid resuscitation, the patient received blood products transfusion of fresh frozen plasma/packed red blood cells/platelet concentrate at a ratio of 1:1:1 and evolved intraoperatively with improvement in perfusion parameters without requiring vasoactive drugs. At the end of the operation, the patient was taken to the intensive care unit and discharged on the seventh postoperative day

Conclusion: : The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defined therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.
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http://dx.doi.org/10.1016/j.bjane.2012.03.006DOI Listing
January 2013

Hemostatic resuscitation in traumatic hemorrhagic shock: case report.

Braz J Anesthesiol 2013 Jan-Feb;63(1):99-102

Anesthesiologist at Department of Anesthesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.

Background And Objectives: The aim of this paper is to report a case in which the damage control resuscitation (DCR) approach was successfully used to promote hemostatic resuscitation in a polytraumatized patient with severe hemorrhagic shock.

Case Report: Female patient, 32 years of age, with severe hemorrhagic shock due to polytrauma with hip fracture, who developed acidosis, coagulopathy, and hypothermia. During fluid resuscitation, the patient received blood products transfusion of fresh frozen plasma/packed red blood cells/platelet concentrate at a ratio of 1:1:1 and evolved intraoperatively with improvement in perfusion parameters without requiring vasoactive drugs. At the end of the operation, the patient was taken to the intensive care unit and discharged on the seventh postoperative day.

Conclusion: The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defined therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.
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http://dx.doi.org/10.1016/S0034-7094(13)70201-0DOI Listing
February 2014

Experimental model of non-controlled hemorrhagic shock in pigs.

Rev Bras Anestesiol 2011 Nov-Dec;61(6):793-7

Faculdade de Medicina da Universidade de São Paulo, Brazil.

Background And Objectives: A better understanding of pathophysiologic changes associated to trauma and hemorrhagic shock can help the development of therapies capable of reducing trauma-related mortality. The objective of this study was to describe a model of non-controlled hemorrhagic shock in pigs.

Methods: Animals received ketamine and midazolam as pre-anesthetic medications. Anesthesia was induced with propofol, and tracheal intubation was performed with the animals on spontaneous ventilation. After intubation neuromuscular blockade was performed. Animals were maintained in controlled mechanical ventilation and normocapnia. Anesthesia was maintained with propofol and fentanyl as needed. Saline was infused during the entire preparation period.

Monitoring: Cardioscope, pulse oximeter, invasive blood pressure, volumetric catheter in the pulmonary artery, and urine output by cystostomy were used. Experimental model: after the initial recording of hemodynamic, metabolic, and coagulation variables, right subcostal incision and left lobe liver biopsy were performed. Anesthetic infusion was reduced while the infusion of saline was interrupted. An incision 12cm long 2cm deep was performed in the right liver lobe followed by digital divulsion of the wound. During the hemorrhagic phase, an aspiration probe was placed close to the wound and the volume of aspirated blood was recorded. When mean arterial pressure reached 40mmHg and bleeding was above 700mL the intervention phase was initiated according to the type of study.

Conclusion: The development of experimental models to reduce high mortality and costs related to trauma is important.
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http://dx.doi.org/10.1016/S0034-7094(11)70089-7DOI Listing
March 2012

Potassium in hemorrhagic shock: a potential marker of tissue hypoxia.

J Trauma 2010 Jun;68(6):1335-41

Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da USP, Avenida Dr. Enéas de Carvalho Aguiar, São Paulo, SP, Brazil.

Background: This study was designed to evaluate serum potassium level variation in a porcine model of hemorrhagic shock (HS).

Methods: Eight pigs were studied in a controlled hemorrhage model of HS. Blood withdrawal began at a 50 mL/min to 70 mL/min rate, adjusted to reach a mean arterial pressure (MAP) level of 60 mm Hg in 10 minutes. When MAP reached 60 mm Hg, the blood withdrawal rate was adjusted to maintain a MAP decrease rate of 10 mm Hg every 2 minutes to 4 minutes. Arterial and mixed venous blood samples were collected at MAP levels of 60 mm Hg, 50 mm Hg, 40 mm Hg, 30 mm Hg, 20 mm Hg, and 10 mm Hg and analyzed for oxygen saturation, Po2, Pco2, potassium, lactate, bicarbonate, hemoglobin, pH, and standard base excess.

Results: Significant increase in serum potassium occurred early in all animals. The rate of rise in serum potassium and its levels accompanied the hemodynamic deterioration. Hyperkalemia (K >5 mmol/L) incidence was 12.5% at 60 mm Hg and 50 mm Hg, 62.5% at 40 mm Hg, 87.5% at 30 mm Hg, and 100% at 20 mm Hg. Strong correlations were found between potassium levels and lactate (R = 0.82), SvO2 (R = 0.87), DeltapH (R = 0.83), and DeltaPco2 (R = 0.82).

Conclusions: Serum potassium increase accompanies the onset of HS. The rise in serum potassium was directly related to the hemodynamic deterioration of HS and strongly correlated with markers of tissue hypoxia.
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http://dx.doi.org/10.1097/TA.0b013e3181dbbb36DOI Listing
June 2010

Hyperkalemia accompanies hemorrhagic shock and correlates with mortality.

Clinics (Sao Paulo) 2009 ;64(6):591-7

Department of Anesthesiology, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.

Objective: This study was designed to evaluate the effects of terlipressin versus fluid resuscitation with normal saline, hypertonic saline or hypertonic-hyperoncotic hydroxyethyl starch, on hemodynamics, metabolics, blood loss and short-term survival in hemorrhagic shock.

Method: Twenty-nine pigs were subjected to severe liver injury and treated 30 min later with either: (1) 2 mg terlipressin in a bolus, (2) placebo-treated controls, (3) 4 mL/kg 7.5% hypertonic NaCl, (4) 4 mL/kg 7.2% hypertonic-hyperoncotic hydroxyethyl starch 200/0.5, or (5) normal saline at three times lost blood volume.

Results: The overall mortality rate was 69%. Blood loss was significantly higher in the hypertonic-hyperoncotic hydroxyethyl starch and normal saline groups than in the terlipressin, hypertonic NaCl and placebo-treated controls groups (p<0.005). Hyperkalemia (K>5 mmol/L) before any treatment occurred in 66% of the patients (80% among non-survivors vs. 22% among survivors, p=0.019). Post-resuscitation hyperkalemia occurred in 86.66% of non-survivors vs. 0% of survivors (p<0.001). Hyperkalemia was the first sign of an unsuccessful outcome for the usual resuscitative procedure and was not related to arterial acidemia. Successfully resuscitated animals showed a significant decrease in serum potassium levels relative to the baseline value.

Conclusion: Hyperkalemia accompanies hemorrhagic shock and, in addition to providing an early sign of the acute ischemic insult severity, may be responsible for cardiac arrest related to hemorrhagic shock.
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http://dx.doi.org/10.1590/s1807-59322009000600016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705155PMC
December 2010

Hypertonic saline solution increases cerebral perfusion pressure during clinical orthotopic liver transplantation for fulminant hepatic failure: preliminary results.

Clinics (Sao Paulo) 2006 Jun 30;61(3):231-8. Epub 2006 Jun 30.

Hospital das Clínicas, São Paulo University Medical School, Brazil.

Unlabelled: During orthotopic liver transplantation for fulminant hepatic failure, some patients may develop sudden deterioration of cerebral perfusion and oxygenation, mainly due to increased intracranial pressure and hypotension, which are likely responsible for postoperative neurological morbidity and mortality. In the present study, we hypothesized that the favorable effects of hypertonic saline solution (NaCl 7.5%, 4 mL/kg) infusion on both systemic and cerebral hemodynamics, demonstrated in laboratory and clinical settings of intracranial hypertension and hemorrhagic shock resuscitation, may attenuate the decrease in cerebral perfusion pressure that often occurs during orthotopic liver transplantation for fulminant hepatic failure.

Methods: 10 patients with fulminant hepatic failure in grade IV encephalopathy undergoing orthotopic liver transplantation with intracranial pressure monitoring were included in this study. The effect on cerebral and systemic hemodynamics in 3 patients who received hypertonic saline solution during anhepatic phase (HSS group) was examined, comparing their data with historical controls obtained from surgical procedure recordings in 7 patients (Control group). The maximal intracranial pressure and the corresponding mean arterial pressure values were collected in 4 time periods: (T1) the last 10 min of the dissection phase, (T2) the first 10 minutes at the beginning of anhepatic phase, (T3) at the end of the anhepatic phase, and (T4) the first 5 minutes after graft reperfusion.

Results: Immediately after hypertonic saline solution infusion, intracranial pressure decreased 50.4%. During the first 5 min of reperfusion, the intracranial pressure remained stable in the HSS group, and all these patients presented an intracranial pressure lower than 20 mm Hg, while in the Control group, the intracranial pressure increased 46.5% (P < 0.001). The HSS group was the most hemodynamically stable; the mean arterial pressure during the first 5 min of reperfusion increased 21.1% in the HSS group and decreased 11.1% in the Control group (P < 0.001). During the first 5 min of reperfusion, cerebral perfusion pressure increased 28.3% in the HSS group while in the Control group the cerebral perfusion pressure decreased 28.5% (P < 0.001). Serum sodium at the end of the anhepatic phase and 3 hours after reperfusion was significantly higher in the HSS group (153.00 +/- 2.66 and 149.00 +/- 1.73 mEq/L) than in the Control group (143.71 +/- 3.30 and 142.43 +/- 1.72 mEq/L), P = 0.003 and P < 0.001 respectively.

Conclusion: Hypertonic saline solution can be successfully used as an adjunct in the neuroprotective strategy during orthotopic liver transplantation for fulminant hepatic failure, reducing intracranial pressure while restoring arterial blood pressure, promoting sustained increase in the cerebral perfusion pressure.
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June 2006
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