Dexametasona no Tratamento da Meningite Bacteriana em Pacientes Subdesenvolvidos

Comentário sobre uso de dexametasona na meningite bacteriana - pode ser útil, desde que a meningite seja microbiologicamente confirmada e não haja um número desproporcional na população de pacientes HIV positivo.

Clique no título para o link do artigo.

In a study conducted in Vietnam, Dr. Jeremy J. Farrar and colleagues show that dexamethasone is only effective if given to patients with confirmed bacterial meningitis, not to those with probable disease. In fact, giving the drug to patients with probable disease seemed to increase the risk of death at 1 month.

The findings from the second study, conducted in a sub-Saharan African city with a high HIV prevalence, indicated little or no benefit of using the corticosteroid for this indication. The results of both studies are reported in The New England Journal of Medicine for December 13th.

"Dexamethasone is a very, very cheap drug and probably because there is no industry interest there has remained a question for more than 30 years as to whether it reduces mortality in patients with meningitis," Dr. Farrar, from the John Radcliffe Hospital in Oxford, UK, told Reuters Health.

The results of this study indicate that the drug can produce a "major" reduction in morbidity and mortality if the patient has confirmed disease, Dr. Farrar said.

This last part is important, he emphasized, because in the developing world, TB meningitis is fairly common and can mimic bacterial meningitis, which refers to meningitis caused by non-TB bacteria, usually Streptococcus pneumoniae or Neisseria meningitidis.

The study involved 435 adolescents and adults with suspected bacterial meningitis who were randomized to receive intravenous dexamethasone or placebo for 4 days in addition to a 10- to 14-day course of ceftriaxone. Some of the patients had received antibiotics before inclusion in the study. All of the patients were HIV-negative.

Sixty-nine percent of patients had confirmed bacterial meningitis, 28.3% had probable meningitis, and 2.8% had an alternative diagnosis.

In the overall analysis, dexamethasone therapy did not reduce mortality at 1 month or the risk of death or disability at 6 months. When the analysis was confined to patients with confirmed bacterial meningitis, however, use of the drug reduced 1-month mortality by 57% and the 6-month risk of death or disability by 44%.

As noted, use of dexamethasone for probable bacterial meningitis appeared to increase the risk of death at 1 month. The researchers believe that this is because many of the cases of probable bacterial meningitis actually had TB meningitis, which responded adversely to the drug.

"From this study, if you have an adult patient who is HIV-negative, in whom you confirm acute bacterial meningitis, you should give steroids, even if the patient has had antibiotics before coming to the hospital," Dr. Farrar said. "It also shows how important good diagnostic laboratories are and that by having good laboratories making a quick diagnosis, you can reduce death by a half."

In the second study, which was centered in Blantyre, Malawi, Dr. Matthew Scarborough, also from the John Radcliffe Hospital in Oxford, UK, and colleagues assessed the outcomes of 465 patients who were admitted with bacterial meningitis and randomized to receive intravenous dexamethasone or placebo in combination with intramuscular or intravenous ceftriaxone. In contrast to the first study, 90% of the subjects were HIV-positive.

Dexamethasone therapy did not reduce morbidity or mortality in the study group. Ceftriaxone efficacy was not significantly influenced by its route of administration.

"This trial does not provide support for the routine inclusion of corticosteroids in the management of adult bacterial meningitis in resource-poor areas where pneumococcus is the primary pathogen and where a substantial proportion of patients are likely to have advanced HIV disease," the authors conclude.

Lorazepam x Dexmedetomedina no Tratamento do Delirium

Artigo publicado no JAMA mostrando redução da incidência de delirium nos pacientes sedados com dexmedetomidina.

Clicar no título para visualizar o abstract do artigo.

"Patients receiving mechanical ventilation in an intensive care unit (ICU) who were given dexmedetomidine for sedation had more days without delirium or coma and significantly more time at the desired level of sedation vs similar patients who received the standard sedative lorazepam, according to a study in the December 12 issue of the Journal of the American Medical Association.

The study also reported less mortality among patients receiving dexmedetomidine vs those receiving lorazepam, although this result was not statistically significant.

Lorazepam, a benzodiazepine drug, is routinely given to patients in ICU to reduce pain and anxiety and to allow them to tolerate invasive procedures, but these study results may change that treatment approach. "I think these data suggest that changing sedation paradigms is something that we need to do," said Pratik P. Pandharipande, MD, MSCI, assistant professor of anesthesiology and critical care, Vanderbilt University Medical Center in Nashville, Tennessee, who was lead author for the study."

In previous research, investigators had noted that delirium occurs in up to 80% of patients on a respirator in the ICU, said Dr. Pandharipande. They also observed that lorazepam may contribute to an increased risk for delirium and coma. Lorazepam may cause such brain dysfunction by activating γ-aminobutyric acid central nervous system receptors that alter levels of neurotransmitters such as dopamine and serotonin. Benzodiazepine drugs also impair the quality of sleep by suppressing slow-wave (deep non–rapid eye movement) sleep, thereby perhaps contributing to delirium, said the authors.

Dexmedetomidine works on different receptors — alpha-2 receptors — and preserves slow-wave sleep.

This double-blind trial enrolled 106 adult patients in an ICU who needed mechanical ventilation between August 2004 and April 2006. They were randomized to receive sedation with either dexmedetomidine (52 patients) or lorazepam (51 patients) for as long as 120 hours at Washington Hospital Center or Vanderbilt University Medical Center (3 patients were withdrawn after randomization). Nurses treated pain with doses of fentanyl based on physiological parameters including blood pressure, heart and respiratory rates, facial expression, and limb movement.

Delirium was measured with use of the Confusion Assessment Method for the ICU (CAM-ICU). Patients were categorized as having delirium if they had a Richmond Agitation-Sedation Scale (RASS) score of –3 or greater. Coma was defined as a RASS score of –4 (responsive only to physical touch) or –5 (unresponsive to physical stimulus).

More Days Without Delirium

The researchers found that approximately 30% fewer patients experienced coma in the dexmedetomidine vs the lorazepam group (63% vs 92%) and that the patients receiving dexmedetomidine had more days alive without delirium or coma (median, 7 vs 3).

"We found that in a 12-day evaluation period . . . even though the groups were balanced as far as their age, demographics, etc, were concerned, patients on dexmedetomidine had a median or an average duration of being free of delirium and coma about 4 days more than the lorazepam group," commented Dr. Pandharipande.

As well, patients sedated with dexmedetomidine spent more time at the level of sedation targeted by both nurses and physicians, and although this was not statistically significant, they had more ventilator-free days than patients receiving the standard drug (22 vs 18 days).

As for pain control, patients treated with dexmedetomidine received more fentanyl than those treated with lorazepam. This could be because they were less likely to be delirious or in a coma and thus were more able to communicate their need for an analgesic, or because the pain drug was being used for its sedating properties, said the study authors.

Patients in the study who were not delirious or in a coma underwent neuropsychological testing within 72 hours of discharge from ICU. In the dexmedetomidine group, 42% of patients could be tested but only 31% in the lorazepam group, noted Dr. Pandharipande.

Changing Sedation May Improve Mortality Rate

The investigators also looked at 28-day mortality and reported a 10% reduction in the dexmedetomidine group (17% vs 27% in the lorazopam group). "We were not powered to study mortality so from a statistical standpoint, it was not significant, but I think if we had more patients in the study group, that would have been a very significant result," said Dr. Pandharipande. He added that researchers are planning a larger study "to look at whether changing sedation paradigms actually improves mortality."

Although there was a higher cost of care associated with patients in the dexmedetomidine group before their enrolment in the study, the total cost of care in the ICU was comparable for the 2 groups. "If you look at ICU costs, if you look at pharmacy bills, if you look at respiratory care costs, they were comparable in the 2 groups because those factor in only after a patient hits the ICU," Dr. Pandharipande told Medscape Neurology and Neurosurgery. So although dexmedetomidine is a more expensive drug than lorazepam, "the other costs were reduced and therefore they balanced out," he said.

Função adrenal e sepse

Para incrementar os conhecimentos e a discussão sobre insuficiência adrenal o recém-publicado artigo.
As vesperas da publicação do estudo CORTICUS mais um estudo interessante...

clique no título acima para ir ao artigo original

Adrenal function in different subgroups of septic shock patients.
Salgado DR, Rocco JR, Rosso Verdeal JC.

Acta Anaesthesiol Scand. 2007 Nov 12

Background: Relative adrenal insufficiency (RAI) is a common complication during septic shock and may be more frequent in specific subgroups. The main objectives of this study were to determine the adrenal function and the RAI incidence in different subgroups of septic shock patients considering: main admission categories (medical, elective or emergency surgery); source of infection; nosocomial or community-acquired infections; gender, age <65 years or >65 years; and the presence or absence of neurological diseases, acute respiratory distress syndrome (ARDS) and bacteremia. Methods: Prospective study in a medical-surgical ICU, including adults with septic shock, from May 2002 to May 2005. All patients had total serum cortisol measured at baseline and 60 min after a high-dose ACTH test within the first 96 h of shock onset. RAI was defined as a serum cortisol increment after ACTH test (Deltamax(249)) <90 mug/l. Results: One hundred and two subjects were enrolled, and the overall RAI incidence was 22.5%. Patients with ARDS before ACTH test or bacteremia showed lower Deltamax(249) values than patients with ARDS after ACTH test (96 vs. 153 mug/l, P=0.02) or without bacteremia (140 vs. 175 mug/l, P=0.04). Multivariate regression analysis revealed that female gender, development of ARDS before ACTH test, and bacteremia were associated with greater RAI incidence. There was no difference in RAI incidence considering neurological diseases, age, type and source of infection and the main admission categories. Conclusions: Female gender, bacteremia and early-onset ARDS were variables independently associated with greater RAI incidence in septic shock patients. There was no difference in the RAI incidence concerning other subgroups.

Preoperative Evaluation of the Patient With Pulmonary Disease

Com pacientes de alto risco aumentando e número de procedimentos invasivos crescentes é fundamental que possamos estratificar o risco adequadamente permitindo intervenções mais seguras.

clique no título para ir até o artigo original.

no Chest de novembro 2007

Preoperative Evaluation of the Patient With Pulmonary Disease*
Srinivas R. Bapoje, MD, MPH; Julia Feliz Whitaker, MD; Tara Schulz, MD; Eugene S. Chu, MD and Richard K. Albert, MD, FCCP

Abstract

Preoperative pulmonary evaluation is important in the management of patients with lung disease who are undergoing elective cardiothoracic or noncardiothoracic surgery. In some instances, preoperative pulmonary evaluations may also contribute to the management of patients being considered for urgent surgery. The incidence of postoperative pulmonary complications (PPCs) is high and is associated with substantial morbidity and mortality, and prolonged hospital stays. Perioperative pulmonary complications in patients undergoing elective noncardiothoracic surgery can be more accurately predicted than in patients undergoing elective cardiothoracic surgery. Effective strategies to prevent complications in the postoperative period are few. Incentive spirometry and continuous positive airway pressure are the only modalities of proven benefit. Identifying patients who are at risk for the development of PPCs and managing their underlying modifiable risk factors aggressively prior to surgery is essential.