Ventilação mandatória intermitente sincronizada versus ventilação com suporte pressórico e volume garantido em coelhos induzidos à hemorragia aguda

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Repercussões hemodinâmicas do posicionamento em litotomia exagerada para histerectomia vaginal em paciente cardiopata: relato de caso

JUSTIFICATIVA E OBJETIVOS: A técnica de histerectomia vaginal possibilita menor tempo operatório e o uso do bloqueio do neuro-eixo, com os benefícios de melhor analgesia pós-operatória e menor resposta sistêmica ao procedimento cirúrgico. O objetivo deste relato foi descrever as alterações hemodinâmicas decorrentes do posicionamento em litotomia exagerada em paciente cardiopata. RELATO do CASO: Paciente de 33 anos, G0P0A0, com história de sangramento uterino anormal e anemia. A ultra-sonografia evidenciava útero miomatoso com volume estimado de 420 cm³. Ela era portadora de trombofilia e miocardiopatia dilatada, com passado de dois acidentes vasculares encefálicos isquêmicos e dois infartos agudos do miocárdio. Foi monitorizada com pressão arterial invasiva e cateter de artéria pulmonar com medida de débito cardíaco contínuo. Realizada raquianestesia com bupivacaína hiperbárica e morfina. A paciente foi posicionada em litotomia exagerada sendo realizada histerectomia total pela técnica de Heaney e salpingectomia bilateral. Como intercorrência intra-operatória apresentou diminuição do índice cardíaco e aumento das pressões de câmaras direitas após o posicionamento, necessitando do uso de dobutamina. CONCLUSÕES: O posicionamento em litotomia exagerada pode ocasionar alterações hemodinâmicas que devem ser consideradas na escolha da técnica cirúrgica.

Spin reversal and magnetization jumps in ErMexMn1-xO3 perovskites (Me = Ni, Co)

The erbium-based manganite ErMnO3 has been partially substituted at the manganese site by the transition-metal elements Ni and Co. The perovskite orthorhombic structure is found from x(Ni) = 0.2-0.5 in the nickel-based solid solution ErNixMn1-xO3, while it can be extended up to x(Co) = 0.7 in the case of cobalt, provided that the synthesis is performed under oxygenation conditions to favor the presence of Co3+. Presence of different magnetic entities (i.e., Er3+, Ni2+, Co2+, Co3+, Mn3+, and Mn4+) leads to quite unusual magnetic properties, characterized by the coexistence of antiferromagnetic and ferromagnetic interactions. In ErNixMn1-xO3, a critical concentration x(crit)(Ni) = 1/3 separates two regimes: spin-canted AF interactions predominate at x < x(crit), while the ferromagnetic behavior is enhanced for x > x(crit). Spin reversal phenomena are present both in the nickel- and cobalt-based compounds. A phenomenological model based on two interacting sublattices, coupled by an antiferromagnetic exchange interaction, explains the inversion of the overall magnetic moment at low temperatures. In this model, the ferromagnetic transition-metal lattice, which orders at T-c, creates a strong local field at the erbium site, polarizing the Er moments in a direction opposite to the applied field. At low temperatures, when the contribution of the paramagnetic erbium sublattice, which varies as T-1, gets larger than the ferromagnetic contribution, the total magnetic moment changes its sign, leading to an overall ferrimagnetic state. The half-substituted compound ErCo0.50Mn0.50O3 was studied in detail, since the magnetization loops present two well-identified anomalies: an intersection of the magnetization branches at low fields, and magnetization jumps at high fields. The influence of the oxidizing conditions was studied in other compositions close to the 50/50 = Mn/Co substitution rate. These anomalies are clearly connected to the spin inversion phenomena and to the simultaneous presence of Co2+ and Co3+ magnetic moments. Dynamical aspects should be considered to well identify the high-field anomaly, since it depends on the magnetic field sweep rate. (C) 2006 Elsevier B.V. All rights reserved.

Microscopical aspects od accessory air breathing through a modified stomach in the armoured catfish Liposarcus anisitsi (Siluriformes, Loricariidae)

The presence of an accessory air breathing mechanism as verified by several authors, is widespread among Loricariidae, where modified parts of the digestive tract act primarily as oxygen-exchange organs. An anatomical and histological analysis was carried out on the stomach and intestine of the armoured catfish Liposarcus anisitsi. The data support the assumption that the modified stomach is responsible for holding air and allows blood oxygenation under hypoxia. Experiments demonstrating survival of air breathing Liposarcus in severely hypoxic water support the hypothesis and are discussed.

Control of breathing in anuran amphibians

The primary role of the respiratory system is to ensure adequate tissue oxygenation, eliminate carbon dioxide and help to regulate acid-base status. To maintain this homeostasis, amphibians possess an array of receptors located at peripheral and central chemoreceptive sites that sense respiration-related variables in both internal and external environments. As in mammals, input from these receptors is integrated at central rhythmogenic and pattern-forming elements in the medulla in a manner that meets the demands determined by the environment within the constraints of the behavior and breathing pattern of the animal. Also as in mammals, while outputs from areas in the midbrain may modulate respiration directly, they do not play a significant role in the production of the normal respiratory rhythm. However, despite these similarities, the breathing patterns of the two classes are different: mammals maintain homeostasis of arterial blood gases through rhythmic and continuous breathing, whereas amphibians display an intermittent pattern of aerial respiration. While the latter is also often rhythmic, it allows a degree of fluctuation in key respiratory variables that has led some to suggest that control is not as tight in these animals. In this review we will focus specifically on recent advances in studies of the control of ventilation in anuran amphibians. This is the group of amphibians that has attracted the most recent attention from respiratory physiologists. (c) 2006 Elsevier B.V. All rights reserved.

Novel allosteric conformation of human HB revealed by the hydration and anion effects on O-2 binding

The effect of anions on the stability of different functional conformations of Hb is examined through the determination of the dependence of O-2 affinity on water activity (a(w)). The control of a(w) is effected by varying the sucrose osmolal concentration in the bathing solution according to the osmotic stress method. Thus, the hydration change following Hb oxygenation is determined as a function of Cl- and of DPG concentration. We find that only similar to 25 additional water molecules bind to human Hb during the deoxy-to-oxy conformation transition in the absence of anions, in contrast with similar to 72 that bind in the presence of more than 50 mM Cl- or more than 15 mu M DPG. We demonstrate that the increase in the hydration change linked with oxygenation is coupled with anion binding to the deoxy-Hb. Hence, we propose that the deoxy-Hb coexists in two allosteric conformations which depend on whether anion is bound or not: the tense T-state, with low oxygen affinity and anion bound, or a new allosteric P-state, with intermediate oxygen affinity and free of bound anions. The intrinsic oxygen affinity of this unforeseen P-state and the differential binding of Cl-, DPG, and H2O between states P and T and P and R are characteristics which are consistent with those expected for a putative intermediate allosteric state of Hb. These findings represent a new opportunity to explore the structure-function relationships of hemoglobin regulation.

The role of hydration on the mechanism of allosteric regulation: In situ measurements of the oxygen-linked kinetics of water binding to hemoglobin

We report here the first direct measurements of changes in protein hydration triggered by a functional binding. This task is achieved by weighing hemoglobin (Hb) and myoglobin films exposed to an atmosphere of 98%, relative humidity during oxygenation. The binding of the first oxygen molecules to Hb tetramer triggers a change in protein conformation, which increases binding affinity to the remaining empty sites giving rise to the appearance of cooperative phenomena. Although crystallographic data have evidenced that this structural change increases the protein water-accessible surface area, isobaric osmotic stress experiments in aqueous cosolutions have shown that water binding is linked to Hb oxygenation. Now we show that the differential hydration between fully oxygenated and fully deoxygenated states of these proteins, determined by weighing protein films with a quartz crystal microbalance, agree with the ones determined by osmotic stress in aqueous cosolutions, from the linkage between protein oxygen affinity and water activity. The agreements prove that the changes in water activity brought about by adding osmolytes to the buffer solution shift biochemical equilibrium in proportion to the number of water molecules associated with the reaction. The concomitant kinetics of oxygen and of water binding to Hb have been also determined. The data show that the binding of water molecules to the extra protein surface exposed on the transition from the low-affinity T to the high-affinity R conformations of hemoglobin is the rate-limiting step of Hb cooperative reaction. This evidences that water binding is a crucial step on the allosteric mechanism regulating cooperative interactions, and suggests the possibility that environmental water activity might be engaged in the kinetic control of some important reactions in vivo.

Purification, crystallization and preliminary X-ray analysis of haemoglobin I from the armoured catfish Liposarcus anisitsi

Liposarcus anisitsi is an armoured catfish that presents accessorial air oxygenation through a modified stomach, which allows this species to survive in waters with very low oxygen content. Analysis of its haemolysate has shown the presence of four haemoglobins; this work focuses on the main component, haemoglobin I. It has been crystallized in two different forms and X-ray diffraction data have been collected to 2.77 and 2.86 Angstrom resolution using synchrotron radiation. Crystals were determined to belong to the space groups C2 and P2(1) and preliminary structural analysis revealed the presence of one tetramer in the asymmetric unit in both crystal forms. The structure was determined using a standard molecular-replacement technique.

Management of Osteonecrosis of the Jaws in Patients With History of Bisphosphonates Therapy

Bisphosphonates are compounds used in the treatment of various metabolic and malignant bone diseases. The relation between the use of bisphosphonates and ostenonecrosis of the jaws as an adverse effect of the drug has been intensely discussed during the last few years, and up to this moment, there is no consensus concerning an ideal treatment modality for this condition. Nevertheless, there is an agreement among researchers that the standard goal for controlling jaw osteonecrosis is to prevent it. Otherwise, the rationale for a randomized controlled trial is that current treatment has proven to be suboptimal, and no consensus has been reached yet on the best strategies to repair the exposed bone once bone necrosis is developed. This article is focused on reporting a case of moderate osteonecrosis of the upper jaw induced by bisphosphonates and discusses a possible role for surgical debridement associated to platelet-rich plasma, hyperbaric oxygen therapy, and the cessation of the bisphosphonate use in managing this type of lesion. Moreover, the dentist, the oral surgeon, and the oncologist need to work together to reach better outcomes.

A complexa fisiopatologia dos episódios vasooclusivos na anemia falciforme

Hemolytic anemia and vasoocclusion are the cardinal clinical features of sickle cell anemia. Vasoocclusion is a complex process involving not only the polymerization of deoxygenated sickle hemoglobin tetramers, but also interactions between sickle erythrocytes, vascular endothelium, platelets, leukocytes, and plasma proteins. The increased adherence of sickle erythrocytes to endothelium has been implicated as an early step in vasoocclusion. Other researchers have focused on leukocytes and platelets which might also contribute to disturbed blood flow. Microvascular occlusion results in acute painful crises, whereas macrovascular occlusion seems to be the cause of organ failure. The anemia results from the markedly shortened circulatory survival of sickle erythrocytes, together with a limited erythropoietic response. The erythropoiesis increases intensively, but it is not enough to balance the increased rate of erythrocytes destruction to maintain normal levels of total erythrocytes and hemoglobin concentrations; mainly by the low oxygen affinity of hemoglobin S and increased 2,3-Diphosphoglycerate. It is very difficult to separate processes leading to anemia or to vasoocclusion. Understanding the involvement of multiple blood componentes in vasoocclusion may elucidate the clinical manifestations and complications of sickle cell anemia, and may give new insights into the preventive and curative therapy.

Antenatal corticosteroid use and clinical evolution of preterm newborn infants

Objectives: To describe the use of antenatal corticosteroid and clinical evolution of preterm babies. Methods: An observational prospective cohort study was carried out. All 463 pregnant women and their 514 newborn babies with gestational age ranging from 23 to 34 weeks, born at the Brazilian Neonatal Research Network units, were evaluated from August 1 to December 31, 2001. The data were obtained through maternal interview, analysis of medical records, and follow-up of the newborn infants. Data analysis was performed with the use of chi-square, t Student, Mann-Whitney, and ANOVA tests and multiple logistic regression, with level of significance set at 5%. Results: Treatment was directly associated with the number of prenatal visits, with maternal hypertension and with the antenatal use of tocolytic agents. Babies from treated pregnant women presented better Apgar scores at the 1st and 5th minute, reduced need for intervention in the delivery room and lower SNAPPE II. They were born with higher birth weight, longer gestational age and needed less surfactant use, ventilation, and oxygenation time. After multiple logistic regression, the use of antenatal corticosteroid independently improved birth conditions, decreased ventilation time, being related to increased occurrence of neonatal sepsis. Conclusions: The use of corticosteroid was associated with better prenatal care and birth conditions, better preterm evolution but higher risk of infection. Copyright © 2004 by Sociedade Brasileira de Pediatria.

Acute and sustained effects of early administration of inhaled nitric oxide to children with acute respiratory distress syndrome

OBJECTIVE: To determine the acute and sustained effects of early inhaled nitric oxide on some oxygenation indexes and ventilator settings and to compare inhaled nitric oxide administration and conventional therapy on mortality rate, length of stay in intensive care, and duration of mechanical ventilation in children with acute respiratory distress syndrome. DESIGN: Observational study. SETTING: Pediatric intensive care unit at a university-affiliated hospital. PATIENTS: Children with acute respiratory distress syndrome, aged between 1 month and 12 yrs. INTERVENTIONS: Two groups were studied: an inhaled nitric oxide group (iNOG, n = 18) composed of patients prospectively enrolled from November 2000 to November 2002, and a conventional therapy group (CTG, n = 21) consisting of historical control patients admitted from August 1998 to August 2000. MEASUREMENTS AND MAIN RESULTS: Therapy with inhaled nitric oxide was introduced as early as 1.5 hrs after acute respiratory distress syndrome diagnosis with acute improvements in Pao(2)/Fio(2) ratio (83.7%) and oxygenation index (46.7%). Study groups were of similar ages, gender, primary diagnoses, pediatric risk of mortality score, and mean airway pressure. Pao(2)/Fio(2) ratio was lower (CTG, 116.9 +/- 34.5; iNOG, 62.5 +/- 12.8, p <.0001) and oxygenation index higher (CTG, 15.2 [range, 7.2-32.2]; iNOG, 24.3 [range, 16.3-70.4], p <.0001) in the iNOG. Prolonged treatment was associated with improved oxygenation, so that Fio(2) and peak inspiratory pressure could be quickly and significantly reduced. Mortality rate for inhaled nitric oxide-patients was lower (CTG, ten of 21, 47.6%; iNOG, three of 18, 16.6%, p <.001). There was no difference in intensive care stay (CTG, 10 days [range, 2-49]; iNOG, 12 [range, 6-26], p >.05) or duration of mechanical ventilation (TCG, 9 days [range, 2-47]; iNOG, 10 [range, 4-25], p >.05). CONCLUSIONS: Early treatment with inhaled nitric oxide causes acute and sustained improvement in oxygenation, with earlier reduction of ventilator settings, which might contribute to reduce the mortality rate in children with acute respiratory distress syndrome. Length of stay in intensive care and duration of mechanical ventilation are not changed. Prospective trials of inhaled nitric oxide early in the setting of acute lung injury in children are needed.

Sildenafil for pulmonary hypertension treatment after cardiac surgery

Objective: To report on the use of sildenafil for pulmonary hypertension treatment of a newborn patient after cardiac surgery. Description: A female, full term newborn infant with diagnosis of double outlet right ventricle, pulmonary hypoplasia and subaortic ventricular septal defect, was submitted to Blalock surgery in the first week of life. In postoperative the newborn had pulmonary hypertension and persistent hypoxia, without response to nitric oxide, but with improved oxygenation after continuous intravenous infusion of prostaglandin E1. After several failed attempts to discontinue prostaglandin E1, oral sildenafil was used. There was a decrease in pulmonary vascular resistance with consequent oxygenation improvement and 48 hours later it was possible to discontinue prostaglandin E1 infusion. Comments: Sildenafil can be an alternative therapy for pulmonary hypertension, especially when there is no response to conventional therapy. Copyright © 2005 by Sociedade Brasileira de Pediatria.

Estudo comparativo dos efeitos hemodinâmicos e ventilatórios da ventilação controlada a volume ou a pressão, em cães submetidos ao pneumoperitônio

BACKGROUND AND OBJECTIVES: Pressure controlled ventilation (PCV) is available in anesthesia machines, but there are no studies on its use during CO 2 pneumoperitoneum (CPP). This study aimed at evaluating pressure-controlled ventilation and hemodynamic and ventilatory changes during CPP, as compared to conventional volume controlled ventilation (VCV). METHODS: This study involved 16 dogs anesthetized with thiopental, fentanyl and pancuronium, which were randomly assigned to two groups: VC - volume controlled ventilation (n=8) and PC - pressure controlled ventilation (n=8). Hemodynamic and ventilatory parameters were monitored and recorded in 4 moments: M1 (before CPP), M2 (30 minutes after CPP = 10 mmHg), M3 (30 minutes after CPP=15 mmHg) and M4 (30 minutes after deflation). RESULTS: With CPP, there has been significant increase in tidal volume in PC group; there has been increase in airway pressures (peak and plateau), decrease in compliance with increase in CPP pressure, increase in heart rate, maintenance of mean blood pressure with higher values in the VC group in all stages; there was also increase in right atrium pressure with significant decrease after deflation, decrease in arterial pH with minor variations in PC group, greater arterial pCO 2 stability in PC group, and no significant changes in arterial pO 2. CONCLUSIONS: There were some differences in hemodynamic and ventilatory data between both ventilation control modes (VC and PC). It is possible to use pressure controlled ventilation during CPP, but the anesthesiologist must monitor and take a close look at alveolar ventilation, adjusting inspiratory pressure to ensure proper CO 2 elimination and oxygenation. © Sociedade Brasileira de Anestesiologia, 2005.