Publications by authors named "Maria José Carvalho Carmona"

82 Publications

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

Emergence delirium in children: a Brazilian survey.

Braz J Anesthesiol 2021 Apr 3. Epub 2021 Apr 3.

Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clinicas (HC), Disciplina de Anestesiologia, Sao Paulo, SP, Brazil.

Background: Pediatric emergence delirium is characterized by a disturbance of a child's awareness during the early postoperative period that manifests as disorientation, altered attention and perception. The incidence of emergence delirium varies between 18% and 80% depending on risk factors and how it is measured. Reports from Canada, Germany, Italy, United Kingdom, and France demonstrated a wide range of preventive measures and definitions, indicating that there is a lack of clarity regarding emergence delirium. We aimed to assess the practices and beliefs among Brazilian anesthesiologists regarding emergence delirium.

Methods: A web-based survey was developed using REDCap®. A link and QR Code were sent by email to all Brazilian anesthesiologists associated with the Brazilian Society of Anesthesiology (SBA).

Results: We collected 671 completed questionnaires. The majority of respondents (97%) considered emergence delirium a relevant adverse event. Thirty-two percent of respondents reported routinely administrating medication to prevent emergence delirium, with clonidine (16%) and propofol (15%) being the most commonly prescribed medications. More than 70% of respondents reported a high level of patient and parent anxiety, a previous history of emergence delirium, and untreated pain as risk factors for emergence delirium. Regarding treatment, thirty-five percent of respondents reported using propofol, followed by midazolam (26%).

Conclusion: Although most respondents considered emergence delirium a relevant adverse event, only one-third of them routinely applied preventive measures. Clonidine and propofol were the first choices for pharmacological prevention. For treatment, propofol and midazolam were the most commonly prescribed medications.
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http://dx.doi.org/10.1016/j.bjane.2020.12.029DOI Listing
April 2021

A call for more pediatric anesthesia research.

Braz J Anesthesiol 2021 Jan-Feb;71(1):1-3. Epub 2020 Dec 24.

Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clínicas (HC), Disciplina de Anestesiologia, São Paulo, SP, Brazil.

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http://dx.doi.org/10.1016/j.bjane.2020.12.001DOI Listing
December 2020

A Brazilian national preparedness survey of anesthesiologists during the coronavirus pandemic.

Braz J Anesthesiol 2021 Mar-Apr;71(2):184-187. Epub 2021 Feb 19.

Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Disciplina de Anestesiologia, São Paulo, SP, Brazil.

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http://dx.doi.org/10.1016/j.bjane.2021.02.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972987PMC
May 2021

ESPID – escore simplificado preditivo de intubação difícil.

Rev Bras Anestesiol 2020 Nov-Dec;70(6):569. Epub 2020 Nov 1.

Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, São Paulo, SP, Brasil.

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http://dx.doi.org/10.1016/j.bjan.2020.10.004DOI Listing
November 2020

Intraoperative pulmonary hyperdistention estimated by transthoracic lung ultrasound: A pilot study.

Anaesth Crit Care Pain Med 2020 12 17;39(6):825-831. Epub 2020 Oct 17.

Divisão de Anestesiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil.

Introduction: Transthoracic lung ultrasound can assess atelectasis reversal and is considered as unable to detect associated hyperdistention. In this study, we describe an ultrasound pattern highly suggestive of pulmonary hyperdistention.

Methods: Eighteen patients with normal lungs undergoing lower abdominal surgery were studied. Electrical impedance tomography was calibrated, followed by anaesthetic induction, intubation and mechanical ventilation. To reverse posterior atelectasis, a recruitment manoeuvre was performed. Positive-end expiratory pressure (PEEP) titration was then obtained during a descending trial - 20, 18, 16, 14, 12, 10, 8, 6 and 4cmHO. Ultrasound and electrical impedance tomography data were collected at each PEEP level and interpreted by two independent observers. Spearman correlation test and receiving operating characteristic curve were used to compare lung ultrasound and electrical impedance tomography data.

Results: The number of horizontal A lines increased linearly with PEEP: from 3 (0, 5) at PEEP 4cmHO to 10 (8, 13) at PEEP 20cmHO. The increase number of A lines was associated with a parallel and significant decrease in intercostal space thickness (p=0.001). The lung ultrasound threshold for detecting pulmonary hyperdistention was defined as the number of A lines counted at the PEEP preceding the PEEP providing the best respiratory compliance. Six A lines was the median threshold for detecting pulmonary hyperdistention. The area under the receiving operating characteristic curve was 0.947.

Conclusions: Intraoperative transthoracic lung ultrasound can detect lung hyperdistention during a PEEP descending trial. Six or more A lines detected in normally aerated regions can be considered as indicating lung hyperdistention.

Trial Registration: NCT02314845 Registered on ClinicalTrials.gov.
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http://dx.doi.org/10.1016/j.accpm.2020.09.009DOI Listing
December 2020

Characteristics and outcomes of patients with COVID-19 admitted to the ICU in a university hospital in São Paulo, Brazil - study protocol.

Clinics (Sao Paulo) 2020 26;75:e2294. Epub 2020 Aug 26.

Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.

Objectives: We designed a cohort study to describe characteristics and outcomes of patients with coronavirus disease (COVID-19) admitted to the intensive care unit (ICU) in the largest public hospital in Sao Paulo, Brazil, as Latin America becomes the epicenter of the pandemic.

Methods: This is the protocol for a study being conducted at an academic hospital in Brazil with 300 adult ICU beds dedicated to COVID-19 patients. We will include adult patients admitted to the ICU with suspected or confirmed COVID-19 during the study period. The main outcome is ICU survival at 28 days. Data will be collected prospectively and retrospectively by trained investigators from the hospital's electronic medical records, using an electronic data capture tool. We will collect data on demographics, comorbidities, severity of disease, and laboratorial test results at admission. Information on the need for advanced life support and ventilator parameters will be collected during ICU stay. Patients will be followed up for 28 days in the ICU and 60 days in the hospital. We will plot Kaplan-Meier curves to estimate ICU and hospital survival and perform survival analysis using the Cox proportional hazards model to identify the main risk factors for mortality. ClinicalTrials.gov: NCT04378582.

Results: We expect to include a large sample of patients with COVID-19 admitted to the ICU and to be able to provide data on admission characteristics, use of advanced life support, ICU survival at 28 days, and hospital survival at 60 days.

Conclusions: This study will provide epidemiological data about critically ill patients with COVID-19 in Brazil, which could inform health policy and resource allocation in low- and middle-income countries.
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http://dx.doi.org/10.6061/clinics/2020/e2294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442378PMC
September 2020

Recommendations for Cardiopulmonary Resuscitation (CPR) of patients with suspected or confirmed COVID-19.

Braz J Anesthesiol 2020 Jun 13. Epub 2020 Jun 13.

Sociedade Brasileira de Cardiologia (SBC), Rio de Janeiro, RJ, Brazil.

The care for patients suffering from cardiopulmonary arrest in a context of a COVID-19 pandemic has particularities that should be highlighted. The following recommendations from the Brazilian Association of Emergency Medicine (ABRAMEDE), the Brazilian Society of Cardiology (SBC) and the Brazilian Association of Intensive Medicine (AMIB) and the Brazilian Society of Anesthesiology (SBA), associations and societies official representatives of specialties affiliated to the Brazilian Medical Association (AMB), aim to guide the various assistant teams, in a context of little solid evidence, maximizing the protection of teams and patients. It is essential to wear full Personal Protective Equipment (PPE) for aerosols during the care of Cardiopulmonary Resuscitation (CPR) and it is imperative to consider and treat the potential causes in these patients, especially hypoxia and arrhythmias caused by changes in the QT interval or myocarditis. The installation of an advanced invasive airway must be obtained early and the use of High Efficiency Particulate Arrestance (HEPA) filters at the interface with the valve bag is mandatory; situations of occurrence of CPR during mechanical ventilation and in a prone position demand peculiarities that are different from the conventional CPR pattern. Faced with the care of a patient diagnosed or suspected of COVID-19, the care follows the national and international protocols and guidelines 2015 ILCOR (International Alliance of Resuscitation Committees), AHA 2019 Guidelines (American Heart Association) and the Update of the Cardiopulmonary Resuscitation and Emergency Care Directive of the Brazilian Society of Cardiology 2019.
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http://dx.doi.org/10.1016/j.bjane.2020.06.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293473PMC
June 2020

[Volemia and kidney transplantation].

Rev Bras Anestesiol 2020 May - Jun;70(3):191-193

Universidade de São Paulo (USP), Faculdade de Medicina, São Paulo, SP, Brasil.

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http://dx.doi.org/10.1016/j.bjan.2020.06.003DOI Listing
September 2020

Approach to Endoscopic Procedures: A Routine Protocol from a Quaternary University Referral Center Exclusively for Coronavirus Disease 2019 Patients.

Clinics (Sao Paulo) 2020 12;75:e1989. Epub 2020 Jun 12.

Unidade de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.

Objectives: The present coronavirus disease (COVID-19) pandemic has ushered in an unprecedented era of quality control that has necessitated advanced safety precautions and the need to ensure the adequate protection of healthcare professionals (HCPs). Endoscopy units, endoscopists, and other HCP may be at a significant risk for transmission of the virus. Given the immense burden on the healthcare system and surge in the number of patients with COVID-19, well-designed protocols and recommendations are needed. We aimed to systematically characterize our approach to endoscopic procedures in a quaternary university hospital setting and provide summary protocol recommendations.

Method: This descriptive study details a COVID-19-specific protocol designed to minimize infection risks to patients and healthcare workers in the endoscopy unit.

Results: Our institution, located in São Paulo, Brazil, includes a 900-bed hospital, with a 200-bed-specific intensive care unit exclusively designed for patients with moderate and severe COVID-19. We highlighted recommendations for infection prevention and control during endoscopic procedures, including appropriate triage and screening, outpatient management and procedural recommendations, role and usage of personal protective equipment (PPE), and role and procedural logistics involving COVID-19-positive patients. We also detailed hospital protocols for reprocessing endoscopes and cleaning rooms and also provided recommendations to minimize severe acute respiratory syndrome coronavirus 2 transmission.

Conclusion: This COVID-19-specific administrative and clinical protocol can be replicated or adapted in multiple institutions and endoscopy units worldwide. Furthermore, the recommendations and summary protocol may improve patient and HCP safety in these trying times.
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http://dx.doi.org/10.6061/clinics/2020/e1989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247750PMC
June 2020

[Patient 4.0 - The challenge of care for elderly patients].

Rev Bras Anestesiol 2020 Jan - Feb;70(1):1-2

Hospital Sírio Libanês, São Paulo, SP, Brasil.

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http://dx.doi.org/10.1016/j.bjan.2020.03.001DOI Listing
September 2020

[Impact of Grade I obesity on respiratory mechanics during video laparoscopic surgery: prospective longitudinal study].

Rev Bras Anestesiol 2020 Mar - Apr;70(2):90-96. Epub 2020 Feb 20.

Universidade de São Paulo (USP), Faculdade de Medicina (FM), Hospital das Clínicas (HC), São Paulo, SP, Brasil.

Introduction And Objectives: The association pneumoperitoneum and obesity in video laparoscopy can contribute to pulmonary complications, but has not been well defined in specific groups of obese individuals. We assessed the effects of pneumoperitoneum in respiratory mechanics in Grade I obese compared to non-obese.

Methods: Prospective study including 20 patients submitted to video laparoscopic cholecystectomy, normal spirometry, divided into non-obese (BMI ≤ 25kg.m) and obese (BMI > 30kg.mg), excluding Grade II and III obese. We measured pulmonary ventilation mechanics data before pneumoperitoneum (baseline), and five, fifteen and thirty minutes after peritoneal insufflation, and fifteen minutes after disinflation (final).

Results: Mean BMI of non-obese was 22.72 ± 1.43kg.m and of the obese 31.78 ± 1.09kg.m, p < 0.01. Duration of anesthesia and of peritoneal insufflation was similar between groups. Baseline pulmonary compliance (Crs) of the obese (38.3 ± 8.3mL.cm HO) was lower than of the non-obese (47.4 ± 5.7mL.cm HO), p = 0.01. After insufflation, Crs decreased in both groups and remained even lower in the obese at all moments assessed (GLM p < 0.01). Respiratory system peak pressure and plateau pressure were higher in the obese, albeit variations were similar at moments analyzed (GLM p > 0.05). The same occurred with elastic pressure, higher in the obese at all times (GLM p = 0.04), and resistive pressure showed differences in variations between groups during pneumoperitoneum (GLM p = 0,05).

Conclusions: Grade I obese presented more changes in pulmonary mechanics than the non-obese during video laparoscopies and the fact requires mechanical ventilation-related care.
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http://dx.doi.org/10.1016/j.bjan.2019.12.001DOI Listing
February 2020

Nebulization of Vancomycin Provides Higher Lung Tissue Concentrations than Intravenous Administration in Ventilated Female Piglets with Healthy Lungs.

Anesthesiology 2020 06;132(6):1516-1527

From the Laboratory of Anesthesiology, School of Medicine, São Paulo University, São Paulo, Brazil (C.L.d.M.M., M.J.C.C., D.R.R.M., J.O.C.A., D.A.O.) Laboratory of Clinical and Experimental Pharmacology, Department of Pharmacology, Institute of Biological Sciences, Federal University of Juiz de Fora, Juiz de Fora, Brazil (J.W.L.N., A.C.R.) Anesthesiology Division, School of Medicine, Pontifical Catholic University of Chile, Santiago de Chile, Chile (L.I.C.) Sorbonne University, Multidisciplinary Intensive Care Unit, Pitié-Salpêtrière Hospital, Public Assistance Hospitals of Paris, Paris, France (A.M., J.-J.R.).

Background: Intravenous vancomycin is used to treat ventilator-associated pneumonia caused by methicillin-resistant Staphylococcus aureus, but achieves high rates of failure. Vancomycin nebulization may be efficient to provide high vancomycin lung tissue concentrations. The aim of this study was to compare lung tissue and serum concentrations of vancomycin administered intravenously and by aerosol in mechanically ventilated and anesthetized healthy piglets.

Methods: Twelve female piglets received a single intravenous dose of vancomycin (15 mg/kg) and were killed 1 (n = 6) or 12 h (n = 6) after the end of administration. Twelve piglets received a single nebulized dose of vancomycin (37.5 mg/kg) and were killed 1 (n = 6) or 12 h (n = 6) after the end of the aerosol administration. In each group, vancomycin lung tissue concentrations were assessed on postmortem lung specimens using high-performance liquid chromatography. Blood samples were collected for serum vancomycin concentration measurement 30 min and 1, 2, 4, 6, 8, and 12 h after the end of vancomycin administration. Pharmacokinetics was analyzed by nonlinear mixed effect modeling.

Results: One hour after vancomycin administration, lung tissue concentrations in the aerosol group were 13 times the concentrations in the intravenous group (median and interquartile range: 161 [71, 301] μg/g versus 12 [4, 42] μg/g; P < 0.0001). Twelve hours after vancomycin administration, lung tissue concentrations in the aerosol group were 63 (23, 119) μg/g and 0 (0, 19) μg/g in the intravenous group (P < 0.0001). A two-compartment weight-scaled allometric model with first-order absorption and elimination best fit serum pharmacokinetics after both routes of administration. Area under the time-concentration curve from 0 to 12 h was lower in the aerosol group in comparison to the intravenous group (56 [8, 70] mg · h · l vs. 121 [103, 149] mg · h · l, P = 0.002). Using a population model, vancomycin bioavailability was 13% (95% CI, 6 to 69; coefficient of variation = 85%) and absorption rate was slow (absorption half life = 0.3 h).

Conclusions: Administration of vancomycin by nebulization resulted in higher lung tissue concentrations than the intravenous route.
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http://dx.doi.org/10.1097/ALN.0000000000003171DOI Listing
June 2020

[Reporting guidelines: tools to increase the completeness and transparency of your anesthesiology research paper].

Rev Bras Anestesiol 2019 Sep - Oct;69(5):429-431. Epub 2019 Oct 18.

Universidade de São Paulo, Faculdade de Medicina, Disciplina de Anestesiologia, São Paulo, SP, Brasil. Electronic address:

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http://dx.doi.org/10.1016/j.bjan.2019.09.008DOI Listing
May 2020

A pragmatic multi-center trial of goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery.

BMC Anesthesiol 2017 05 30;17(1):70. Epub 2017 May 30.

Divisão de Anestesia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Enéas Carvalho de Aguiar, 255 2° andar, Cerqueira César, 05403-900, São Paulo, SP, Brazil.

Background: Intraoperative fluid therapy guided by mechanical ventilation-induced pulse-pressure variation (PPV) may improve outcomes after major surgery. We tested this hypothesis in a multi-center study.

Methods: The patients were included in two periods: a first control period (control group; n = 147) in which intraoperative fluids were given according to clinical judgment. After a training period, intraoperative fluid management was titrated to maintain PPV < 10% in 109 surgical patients (PPV group). We performed 1:1 propensity score matching to ensure the groups were comparable with regard to age, weight, duration of surgery, and type of operation. The primary endpoint was postoperative hospital length of stay.

Results: After matching, 84 patients remained in each group. Baseline characteristics, surgical procedure duration and physiological parameters evaluated at the start of surgery were similar between the groups. The volume of crystalloids (4500 mL [3200-6500 mL] versus 5000 mL [3750-8862 mL]; P = 0.01), the number of blood units infused during the surgery (1.7 U [0.9-2.0 U] versus 2.0 U [1.7-2.6 U]; P = 0.01), the fraction of patients transfused (13.1% versus 32.1%; P = 0.003) and the number of patients receiving mechanical ventilation at 24 h (3.2% versus 9.7%; P = 0.027) were smaller postoperatively in PPV group. Intraoperative PPV-based improved the composite outcome of postoperative complications OR 0.59 [95% CI 0.35-0.99] and reduced the postoperative hospital length of stay (8 days [6-14 days] versus 11 days [7-18 days]; P = 0.01).

Conclusions: In high-risk surgeries, PPV-directed volume loading improved postoperative outcomes and decreased the postoperative hospital length of stay.

Trial Registration: ClinicalTrials.gov Identifier; retrospectively registered- NCT03128190.
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http://dx.doi.org/10.1186/s12871-017-0356-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5450107PMC
May 2017

[Cardiac arrest animal model: a simple device for small animals' chest compression].

Rev Bras Anestesiol 2017 Jul - Aug;67(4):440-441. Epub 2017 Apr 14.

Universidade de São Paulo (USP), Faculdade de Medicina, Laboratório de Anestesiologia (LIM-08), São Paulo, SP, Brasil.

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http://dx.doi.org/10.1016/j.bjan.2017.03.007DOI Listing
May 2019

Factor structure and psychometric properties of the Dispositional Resilience Scale among Brazilian adult patients.

Arq Neuropsiquiatr 2016 Dec;74(12):1014-1020

Universidade de São Paulo, Faculdade de Medicina, Departamento de Anestesiologia, Grupo de Controle da Dor, São Paulo SP, Brasil.

Objective: Verifying the psychometrics of a Brazilian version of the Dispositional Resilience Scale (DRS-15).

Methods: Cross-cultural adaptation was done interviewing 65 adult patients. Validation was evaluated by application of the Lipp Brazilian Stress Symptoms Inventory (ISSL), Self-Report Questionnaire (SRQ), and other measures to 575 participants from the psychiatric ambulatories (for borderline personality, anxiety or post-traumatic stress disorders) and non-psychiatric ambulatories (chronic pain, pre-anesthetic consultation and companions for the latter). Temporal stability was verified with 123 participants.

Results: Exploratory factor analysis yielded a three-factor solution. Psychometrics were acceptable (alpha coefficient, 0.71; intraclass correlation coefficient, 0.81). Correlations with the ISSL, SRQ and other measures were noted except for factor 3. In the psychiatric sample, hardiness scores of borderline patients were lower than those of patients with anxiety disorders.

Conclusion: This version of the DRS-15 exhibited good reliability in a sample of Brazilian patients; validity was confirmed in two of the scale factors.
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http://dx.doi.org/10.1590/0004-282X20160148DOI Listing
December 2016

Atorvastatin for high-risk statin-naïve patients undergoing noncardiac surgery: The Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial.

Am Heart J 2017 Feb 9;184:88-96. Epub 2016 Nov 9.

Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil; Duke Clinical Research Institute, Durham, NC.

Preliminary evidence suggests that statins may prevent major perioperative vascular complications.

Methods: We randomized 648 statin-naïve patients who were scheduled for noncardiac surgery and were at risk for a major vascular complication. Patients were randomized to a loading dose of atorvastatin or placebo (80 mg anytime within 18hours before surgery), followed by a maintenance dose of 40 mg (or placebo), started at least 12hours after the surgery, and then 40 mg/d (or placebo) for 7days. The primary outcome was a composite of all-cause mortality, nonfatal myocardial injury after noncardiac surgery, and stroke at 30days.

Results: The primary outcome was observed in 54 (16.6%) of 326 patients in the atorvastatin group and 59 (18.7%) of 316 patients in the placebo group (hazard ratio [HR] 0.87, 95% CI 0.60-1.26, P=.46). No significant effect was observed on the 30-day secondary outcomes of all-cause mortality (4.3% vs 4.1%, respectively; HR 1.14, 95% CI 0.53-2.47, P=.74), nonfatal myocardial infarction (3.4% vs 4.4%, respectively; HR 0.76, 95% CI 0.35-1.68, P=.50), myocardial injury after noncardiac surgery (13.2% vs 16.5%; HR 0.79, 95% CI 0.53-1.19, P=.26), and stroke (0.9% vs 0%, P=.25).

Conclusion: In contrast to the prior observational and trial data, the LOAD trial has neutral results and did not demonstrate a reduction in major cardiovascular complications after a short-term perioperative course of statin in statin-naïve patients undergoing noncardiac surgery. We demonstrated, however, that a large multicenter blinded perioperative statin trial for high-risk statin-naïve patients is feasible and should be done to definitely establish the efficacy and safety of statin in this patient population.
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http://dx.doi.org/10.1016/j.ahj.2016.11.001DOI Listing
February 2017

The effect of prior tetanic stimulation on train-of-four monitoring in paediatric patients: A randomised open-label controlled trial.

Eur J Anaesthesiol 2017 03;34(3):163-168

From the Department of Anesthesiology, Child Institute, Hospital das Clínicas, São Paulo University Medical School, São Paulo, Brazil (RVC, MLAT, MJCC), Department of Anesthesiology and Pain Medicine, Martini General Hospital Groningen, the Netherlands (HDDB).

Background: In clinical research, neuromuscular monitoring must present a stable response for a period of 2 to 5 min before administration of a neuromuscular blocking agent. The time required to reach this stable response may be shortened by applying a 5-s tetanic stimulus.

Objectives: The aim of this study was to test whether tetanic stimulation interferes with onset and recovery times after a single dose of rocuronium 0.6 mg kg followed by spontaneous recovery.

Design: A randomised, open-label, controlled trial.

Setting: A single-centre trial, study period from January 2014 to July 2015.

Patients: Fifty children aged 2 to 11 years scheduled for elective paediatric surgery.

Intervention: Patients were randomly allocated to receive either tetanic stimulation (group T) or not (group C) before calibration of the neuromuscular monitor.

Main Outcome Measures: Onset and recovery times. Initial and final T1 height, time to obtain initial T1 height stability and monitor settings were also analysed.

Results: There was no significant difference in mean onset time [(C: 57.5 (± 16.9) vs. T: 58.3 (± 31.2) s; P = 0.917]. Mean times to normalised train-of-four (TOF) ratios of 0.7, 0.8 and 0.9 were significantly shorter in the tetanic stimulation group [C: 40.1 (±7.9) vs. T: 34.8 (±10) min; P = 0.047, C: 43.8 (±9.4) vs. T: 37.4 (±11) min; P = 0.045 and C: 49.9 (±12.2) vs. T: 41.7 (±13.1) min; P = 0.026, respectively]. The mean time required for T1 height stabilisation was similar in the two groups [C: 195.0 (± 203.0) vs. T: 116.0 (± 81.6) s; P = 0.093], but the initial and final T1 height values were significantly lower in the tetanic stimulation group (C: 98.0 vs. T: 82.7%; P < 0.001 and C: 95.3 vs. T: 69.3%; P < 0.001, respectively).

Conclusion: Tetanic stimulation shortened the mean times to normalised TOF ratios of 0.7, 0.8 and 0.9, but there was no difference in the mean onset time or the mean time required for T1 height stabilisation after a single dose of rocuronium 0.6 mg kg followed by spontaneous recovery in children aged 2 to 11 years.

Trial Registration: Clinicaltrials.gov. identifier: NCT02498678.
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http://dx.doi.org/10.1097/EJA.0000000000000558DOI Listing
March 2017

Metabolic Acidosis Assessment in High-Risk Surgeries: Prognostic Importance.

Anesth Analg 2016 11;123(5):1163-1171

From the *Anesthesiology Department, Hospital das Clinicas-FMUSP, SP, SP/Brazil; †Anesthesiology Department, Hospital do Servidor Público Estadual-IAMSPE, SP, SP/Brazil; and ‡Intensive Care Department, Hospital do Câncer de Barretos, SP, SP/Brazil.

Background: Metabolic acidosis frequently is present in surgical patients; however, different types of metabolic acidosis (hyperlactatemia, hyperchloremia, and others) may have different relationships to perioperative outcomes. We hypothesized that in postoperative surgical patients, distinctive types of metabolic acidosis would correlate differently with the outcomes of high-risk surgeries.

Methods: A prospective, multicenter observational study was performed in 3 different tertiary care hospitals. Patients who required postoperative admission to the intensive care unit (ICU) were included in this study. Patients with a short life expectancy (those with untreated cancer and limited treatment), hepatic failure, renal failure, or a diagnosis of diabetes were excluded. Patients were classified at ICU admission according to the presence and type of metabolic acidosis into 4 groups: those without acidosis, those with a base excess <-4 mmol/L and albumin-corrected anion gap ≤12 mmol/L (hyperchloremic), those with a base excess <-4 mmol/L and increased albumin-corrected anion gap >12 mmol/L, and those with a base excess <-4 mmol/L and hyperlactatemia >2 mmol/L. Furthermore, patients were reclassified 12 hours after admission to the ICU to verify the metabolic acidosis behavior and outcome differences among the groups.

Results: The study included 618 patients. The incidence of acidosis at ICU admission was 59.1%; 23.9% presented with hyperchloremia, 21.3% with hyperlactatemia, 13.9% with increased anion gap, and 40.9% of the patients presented without metabolic acidosis. Patients whose metabolic acidosis persisted for 12 hours had an incidence of ICU complications rates in hyperlactatemia group of 68.8%, increased anion gap of 68.6%, hyperchloremic of 65.8%, and those without acidosis over 12 hours of 59.3%. A Cox regression model for postoperative 30-day mortality showed: in hyperlactatemic acidosis, hazard ratio (HR) = 1.74, 95% confidence interval (CI) = 1.02-2.96; increased anion gap acidosis, HR = 1.68, 95% CI = 0.85-3.81; hyperchloremic acidosis, HR = 1.47, 95% CI = 0.75-2.89, and 10.3% of 30-day mortality rate in patients without acidosis. An adjusted survival curve by Cox regression found a worse 30-day survival in the hyperlactatemic group compared with the other groups (P = .03). Furthermore, in multiple comparisons among groups, patients with hyperlactatemic acidosis were more likely to develop renal dysfunction (P < .001) up to the seventh day postoperatively.

Conclusions: We found that among patients with different types of acidosis, patients who developed hyperlactatemic metabolic acidosis postoperatively showed greater rates of renal dysfunction within 7 days and hyperlactatemic acidosis represented an independent factor on 30-day mortality in high-risk surgical patients.
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http://dx.doi.org/10.1213/ANE.0000000000001575DOI Listing
November 2016

Factor structure and psychometric properties of the Connor-Davidson resilience scale among Brazilian adult patients.

Sao Paulo Med J 2016 May 13. Epub 2016 May 13.

Department of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

Context And Objective: Personal resilience is associated with several mental health outcomes. The Connor-Davidson resilience scale (CD-RISC) is a widely used self-report measurement of resilience. This study aimed to investigate the reliability and validity of a Brazilian Portuguese version of the CD-RISC.

Design And Setting: Cross-sectional validation study carried out in the outpatient clinics of a public university hospital.

Methods: The cross-cultural adaptation followed established guidelines and involved interviews with 65 adults in psychiatric and non-psychiatric outpatient clinics at a teaching hospital. Validation was assessed through concurrent application of the Lipp Brazilian Stress Symptom Inventory (ISSL), Self-Report Questionnaire (SRQ), Sheehan Disability Scales (SDS) and Chronic Pain Grade (CPG) to 575 patients at the same setting. Temporal stability was verified through a second application to 123 participants.

Results: Factor analysis identified four factors, named tenacity, adaptability-tolerance, reliance on support from outside and intuition. The alpha coefficient of 0.93 and intraclass correlation coefficient of 0.84 indicated good internal consistency and temporal stability. Significant correlations between this version of the CD-RISC and the ISSL, SRQ, SDS and CPG were noted. The patients at the outpatient clinic for borderline personality had resilience scores that were significantly lower than those of the patients at the general anxiety or post-traumatic stress outpatient clinics.

Conclusion: This Brazilian Portuguese version of the Connor-Davidson resilience scale exhibited adequate reliability and validity among a sample of Brazilian adult patients.
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http://dx.doi.org/10.1590/1516-3180.2015.02290512DOI Listing
May 2016

Effects of Single Low Dose of Dexamethasone before Noncardiac and Nonneurologic Surgery and General Anesthesia on Postoperative Cognitive Dysfunction-A Phase III Double Blind, Randomized Clinical Trial.

PLoS One 2016 6;11(5):e0152308. Epub 2016 May 6.

Department of Anesthesia, LIM 8 -Laboratory of Anesthesiology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil.

Unlabelled: Postoperative cognitive dysfunction (POCD) is a multifactorial adverse event most frequently in elderly patients. This study evaluated the effect of dexamethasone on POCD incidence after noncardiac and nonneurologic surgery.

Methods: One hundred and forty patients (ASA I-II; age 60-87 years) took part in a prospective phase III, double blind, randomized study involving the administration or not of 8 mg of IV dexamethasone before general anesthesia under bispectral index (BIS) between 35-45 or 46-55. Neuropsychological tests were applied preoperatively and on the 3rd, 7th, 21st, 90th and 180th days after surgery and compared with normative data. S100β was evaluated before and 12 hours after induction of anesthesia. The generalized estimating equations (GEE) method was applied, followed by the posthoc Bonferroni test considering P<0.05 as significant.

Results: On the 3rd postoperative day, POCD was diagnosed in 25.2% and 15.3% of patients receiving dexamethasone, BIS 35-45, and BIS 46-55 groups, respectively. Meanwhile, POCD was present in 68.2% and 27.2% of patients without dexamethasone, BIS 35-45 and BIS 46-55 groups (p<0.0001). Neuropsychological tests showed that dexamethasone associated to BIS 46-55 decreased the incidence of POCD, especially memory and executive function. The administration of dexamethasone might have prevented the postoperative increase in S100β serum levels.

Conclusion: Dexamethasone can reduce the incidence of POCD in elderly patients undergoing surgery, especially when associated with BIS 46-55. The effect of dexamethasone on S100β might be related with some degree of neuroprotection.

Trial Registration: www.clinicaltrials.gov NCT01332812.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0152308PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859565PMC
April 2017

Latex sensitization in patients with myelomeningocele undergoing urological procedures: prevalence and associated factors.

Can J Anaesth 2016 Aug 31;63(8):983-4. Epub 2016 Mar 31.

Clinics Hospital of University of São Paulo Medical School, University of São Paulo Medical School, São Paulo, SP, Brazil.

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http://dx.doi.org/10.1007/s12630-016-0642-xDOI Listing
August 2016

[Hyperglycemia assessment in the post-anesthesia care unit].

Rev Bras Anestesiol 2017 Nov - Dec;67(6):565-570. Epub 2016 Mar 20.

Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas de São Paulo, São Paulo, SP, Brasil.

Background And Objectives: Hyperglycemia in surgical patients may cause serious problems. Analyzing this complication in this scenario contributes to improve the management of these patients. The aim of this study was to evaluate the prevalence of hyperglycemia in the post-anesthetic care unit (PACU) in non-diabetic patients undergoing elective surgery and analyze the possible risk factors associated with this complication.

Methods: We evaluated non-diabetic patients undergoing elective surgeries and admitted in the PACU. Data were collected from medical records through precoded questionnaire. Hyperglycemia was considered when blood glucose was>120mg.dL. Patients with hyperglycemia were compared to normoglycemic ones to assess factors associated with the problem. We excluded patients with endocrine-metabolic disorders, diabetes, children under 18 years, body mass index (BMI) below 18 or above 35, pregnancy, postpartum or breastfeeding, history of drug use, and emergency surgeries.

Results: We evaluated 837 patients. The mean age was 47.8±16.1 years. The prevalence of hyperglycemia in the postoperative period was 26.4%. In multivariate analysis, age (OR=1.031, 95% CI 1.017-1.045); BMI (OR=1.052, 95% CI 1.005-1.101); duration of surgery (OR=1.011, 95% CI 1.008-1.014), history of hypertension (OR=1.620, 95% CI 1.053-2.493), and intraoperative use of corticosteroids (OR=5.465, 95% CI 3.421-8.731) were independent risk factors for postoperative hyperglycemia.

Conclusion: The prevalence of hyperglycemia was high in the PACU, and factors such as age, BMI, corticosteroids, blood pressure, and duration of surgery are strongly related to this complication.
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http://dx.doi.org/10.1016/j.bjan.2015.08.003DOI Listing
May 2019

Lung Perfusion and Ventilation During Cardiopulmonary Bypass Reduces Early Structural Damage to Pulmonary Parenchyma.

Anesth Analg 2016 Apr;122(4):943-52

From the *Discipline of Anesthesiology, LIM 8 - Laboratory of Anesthesiology, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil; †Department of Cardiothoracic Surgery, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; ‡Department of Pathology, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil; §Department of Veterinary Pathology, Faculdade de Medicina Veterinária da Universidade de Sao Paulo, São Paulo, Brazil; and ‖Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Background: It is unclear whether maintaining pulmonary perfusion and ventilation during cardiopulmonary bypass (CPB) reduces pulmonary inflammatory tissue injury compared with standard CPB where the lungs are not ventilated and are minimally perfused. In this study, we tested the hypothesis that maintenance of lung perfusion and ventilation during CPB decreases regional lung inflammation, which may result in less pulmonary structural damage.

Methods: Twenty-seven pigs were randomly allocated into a control group only submitted to sternotomy (n = 8), a standard CPB group (n = 9), or a lung perfusion group (n = 10), in which lung perfusion and ventilation were maintained during CPB. Hemodynamics, gas exchanges, respiratory mechanics, and systemic interleukins (ILs) were determined at baseline (T0), at the end of 90 minutes of CPB (T90), and 180 minutes after CPB (T180). Bronchoalveolar lavage (BAL) ILs were obtained at T0 and T180. Dorsal and ventral left lung tissue samples were examined for optical and electron microscopy.

Results: At T90, there was a transient reduction in PaO2/FIO2 in CPB (126 ± 64 mm Hg) compared with the control and lung perfusion groups (296 ± 46 and 244 ± 57 mm Hg; P < 0.001), returning to baseline at T180. Serum ILs were not different among the groups throughout the study, whereas there were significant increases in BAL IL-6 (P < 0.001), IL-8 (P < 0.001), and IL-10 (P < 0.001) in both CPB and lung perfusion groups compared with the control group. Polymorphonuclear counts within the lung tissue were smaller in the lung perfusion group than in the CPB group (P = 0.006). Electron microscopy demonstrated extrusion of surfactant vesicles into the alveolar spaces and thickening of the alveolar septa in the CPB group, whereas alveolar and capillary histoarchitecture was better preserved in the lung perfusion group.

Conclusions: Maintenance of lung perfusion and ventilation during CPB attenuated early histologic signs of pulmonary inflammation and injury compared with standard CPB. Although increased compared with control animals, there were no differences in serum or BAL IL in animals receiving lung ventilation and perfusion during CPB compared with standard CPB.
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http://dx.doi.org/10.1213/ANE.0000000000001118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7072023PMC
April 2016

Perioperative cardiac arrest: an evolutionary analysis of the intra-operative cardiac arrest incidence in tertiary centers in Brazil.

Braz J Anesthesiol 2016 Mar-Apr;66(2):176-82. Epub 2015 Feb 7.

Discipline of Anesthesiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.

Background: Great changes in medicine have taken place over the last 25 years worldwide. These changes in technologies, patient risks, patient profile, and laws regulating the medicine have impacted the incidence of cardiac arrest. It has been postulated that the incidence of intraoperative cardiac arrest has decreased over the years, especially in developed countries. The authors hypothesized that, as in the rest of the world, the incidence of intraoperative cardiac arrest is decreasing in Brazil, a developing country.

Objectives: The aim of this study was to search the literature to evaluate the publications that relate the incidence of intraoperative cardiac arrest in Brazil and analyze the trend in the incidence of intraoperative cardiac arrest.

Contents: There were 4 articles that met our inclusion criteria, resulting in 204,072 patients undergoing regional or general anesthesia in two tertiary and academic hospitals, totalizing 627 cases of intraoperative cardiac arrest. The mean intraoperative cardiac arrest incidence for the 25 years period was 30.72:10,000 anesthesias. There was a decrease from 39:10,000 anesthesias to 13:10,000 anesthesias in the analyzed period, with the related lethality from 48.3% to 30.8%. Also, the main causes of anesthesia-related cause of mortality changed from machine malfunction and drug overdose to hypovolemia and respiratory causes.

Conclusions: There was a clear reduction in the incidence of intraoperative cardiac arrest in the last 25 years in Brazil. This reduction is seen worldwide and might be a result of multiple factors, including new laws regulating the medicine in Brazil, incorporation of technologies, better human development level of the country, and better patient care.
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http://dx.doi.org/10.1016/j.bjane.2014.06.007DOI Listing
January 2017