GRAZIELA DOS SANTOS ROCHA FERREIRA
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
4 resultados
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- Effect of postoperative goal-directed therapy in cancer patients undergoing high-risk surgery: a randomized clinical trial and meta-analysis(2018) GERENT, Aline Rejane Muller; ALMEIDA, Juliano Pinheiro; FOMINSKIY, Evgeny; LANDONI, Giovanni; OLIVEIRA, Gisele Queiroz de; RIZK, Stephanie Itala; FUKUSHIMA, Julia Tizue; SIMOES, Claudia Marques; RIBEIRO JR., Ulysses; PARK, Clarice Lee; NAKAMURA, Rosana Ely; FRANCO, Rafael Alves; CANDIDO, Patricia Ines; TAVARES, Cintia Rosa; CAMARA, Ligia; FERREIRA, Graziela dos Santos Rocha; ALMEIDA, Elisangela Pinto Marinho de; KALIL FILHO, Roberto; GALAS, Filomena Regina Barbosa Gomes; HAJJAR, Ludhmila AbrahaoBackground: Perioperative goal-directed hemodynamic therapy (GDHT) has been advocated in high-risk patients undergoing noncardiac surgery to reduce postoperative morbidity and mortality. We hypothesized that using cardiac index (CI)-guided GDHT in the postoperative period for patients undergoing high-risk surgery for cancer treatment would reduce 30-day mortality and postoperative complications. Methods: A randomized, parallel-group, superiority trial was performed in a tertiary oncology hospital. All adult patients undergoing high-risk cancer surgery who required intensive care unit admission were randomly allocated to a CI-guided GDHT group or to a usual care group. In the GDHT group, postoperative therapy aimed at CI >= 2.5 L/min/m(2) using fluids, inotropes and red blood cells during the first 8 postoperative hours. The primary outcome was a composite endpoint of 30-day all-cause mortality and severe postoperative complications during the hospital stay. A meta-analysis was also conducted including all randomized trials of postoperative GDHT published from 1966 to May 2017. Results: A total of 128 patients (64 in each group) were randomized. The primary outcome occurred in 34 patients of the GDHT group and in 28 patients of the usual care group (53.1% vs 43.8%, absolute difference 9.4 (95% CI, -7.8 to 25.8); p = 0.3). During the 8-h intervention period more patients in the GDHT group received dobutamine when compared to the usual care group (55% vs 16%, p < 0.001). A meta-analysis of nine randomized trials showed no differences in postoperative mortality (risk ratio 0.85, 95% CI 0.59-1.23; p = 0.4; p for heterogeneity = 0.7; I-2 = 0%) and in the overall complications rate (risk ratio 0.88, 95% CI 0.71-1.08; p = 0.2; p for heterogeneity = 0.07; I-2 = 48%), but a reduced hospital length of stay in the GDHT group (mean difference (MD) - 1.6; 95% CI - 2.75 to -0.46; p = 0.006; p for heterogeneity = 0.002; I-2 = 74%). Conclusions: CI-guided hemodynamic therapy in the first 8 postoperative hours does not reduce 30-day mortality and severe complications during hospital stay when compared to usual care in cancer patients undergoing high-risk surgery.
- Effect of a Perioperative Intra-Aortic Balloon Pump in High-Risk Cardiac Surgery Patients: A Randomized Clinical Trial(2018) FERREIRA, Graziela Santos Rocha; ALMEIDA, Juliano Pinheiro de; LANDONI, Giovanni; VINCENT, Jean Louis; FOMINSKIY, Evgeny; GALAS, Filomena Regina Barbosa Gomes; GAIOTTO, Fabio A.; DALLAN, Luis Oliveira; FRANCO, Rafael Alves; LISBOA, Luiz Augusto; DALLAN, Luis Roberto Palma; FUKUSHIMA, Julia Tizue; RIZK, Stephanie Itala; PARK, Clarice Lee; STRABELLI, Tania Mara; LAGE, Silvia Helena Gelas; CAMARA, Ligia; ZEFERINO, Suely; JARDIM, Jaquelline; ARITA, Elisandra Cristina Trevisan Calvo; RIBEIRO, Juliana Caldas; AYUB-FERREIRA, Silvia Moreira; AULER JR., Jose Otavio Costa; KALIL FILHO, Roberto; JATENE, Fabio Biscegli; HAJJAR, Ludhmila AbrahaoObjectives: The aim of this study was to evaluate the efficacy of perioperative intra-aortic balloon pump use in high-risk cardiac surgery patients. Design: A single-center randomized controlled trial and a meta-analysis of randomized controlled trials. Setting: Heart Institute of SAo Paulo University. Patients: High-risk patients undergoing elective coronary artery bypass surgery. Intervention: Patients were randomized to receive preskin incision intra-aortic balloon pump insertion after anesthesia induction versus no intra-aortic balloon pump use. Measurements and Main Results: The primary outcome was a composite endpoint of 30-day mortality and major morbidity (cardiogenic shock, stroke, acute renal failure, mediastinitis, prolonged mechanical ventilation, and a need for reoperation). A total of 181 patients (mean [sd] age 65.4 [9.4] yr; 32% female) were randomized. The primary outcome was observed in 43 patients (47.8%) in the intra-aortic balloon pump group and 42 patients (46.2%) in the control group (p = 0.46). The median duration of inotrope use (51hr [interquartile range, 32-94 hr] vs 39hr [interquartile range, 25-66 hr]; p = 0.007) and the ICU length of stay (5 d [interquartile range, 3-8 d] vs 4 d [interquartile range, 3-6 d]; p = 0.035) were longer in the intra-aortic balloon pump group than in the control group. A meta-analysis of 11 randomized controlled trials confirmed a lack of survival improvement in high-risk cardiac surgery patients with perioperative intra-aortic balloon pump use. Conclusions: In high-risk patients undergoing cardiac surgery, the perioperative use of an intra-aortic balloon pump did not reduce the occurrence of a composite outcome of 30-day mortality and major complications compared with usual care alone.
- Intra-aortic balloon pump does not influence cerebral hemodynamics and neurological outcomes in high-risk cardiac patients undergoing cardiac surgery: an analysis of the IABCS trial(2019) CALDAS, Juliana R.; PANERAI, Ronney B.; BOR-SENG-SHU, Edson; FERREIRA, Graziela S. R.; CAMARA, Ligia; PASSOS, Rogerio H.; SALINET, Angela M.; AZEVEDO, Daniel S.; DE-LIMA-OLIVEIRA, Marcelo; GALAS, Filomena R. B. G.; FUKUSHIMA, Julia T.; NOGUEIRA, Ricardo; TACCONE, Fabio S.; LANDONI, Giovanni; ALMEIDA, Juliano P.; ROBINSON, Thompson G.; HAJJAR, Ludhmila A.Background The intra-aortic balloon pump (IABP) is often used in high-risk patients undergoing cardiac surgery to improve coronary perfusion and decrease afterload. The effects of the IABP on cerebral hemodynamics are unknown. We therefore assessed the effect of the IABP on cerebral hemodynamics and on neurological complications in patients undergoing cardiac surgery who were randomized to receive or not receive preoperative IABP in the 'Intra-aortic Balloon Counterpulsation in Patients Undergoing Cardiac Surgery' (IABCS) trial. Methods This is a prospectively planned analysis of the previously published IABCS trial. Patients undergoing elective coronary artery bypass surgery with ventricular ejection fraction <= 40% or EuroSCORE >= 6 received preoperative IABP (n = 90) or no IABP (n = 91). Cerebral blood flow velocity (CBFV) of the middle cerebral artery through transcranial Doppler and blood pressure through Finometer or intra-arterial line were recorded preoperatively (T1) and 24 h (T2) and 7 days after surgery (T3) in patients with preoperative IABP (n = 34) and without IABP (n = 33). Cerebral autoregulation was assessed by the autoregulation index that was estimated from the CBFV response to a step change in blood pressure derived by transfer function analysis. Delirium, stroke and cognitive decline 6 months after surgery were recorded. Results There were no differences between the IABP and control patients in the autoregulation index (T1: 5.5 +/- 1.9 vs. 5.7 +/- 1.7; T2: 4.0 +/- 1.9 vs. 4.1 +/- 1.6; T3: 5.7 +/- 2.0 vs. 5.7 +/- 1.6, p = 0.97) or CBFV (T1: 57.3 +/- 19.4 vs. 59.3 +/- 11.8; T2: 74.0 +/- 21.6 vs. 74.7 +/- 17.5; T3: 71.1 +/- 21.3 vs. 68.1 +/- 15.1 cm/s; p = 0.952) at all time points. Groups were not different regarding postoperative rates of delirium (26.5% vs. 24.2%, p = 0.83), stroke (3.0% vs. 2.9%, p = 1.00) or cognitive decline through analysis of the Mini-Mental State Examination (16.7% vs. 40.7%; p = 0.07) and Montreal Cognitive Assessment (79.16% vs. 81.5%; p = 1.00). Conclusions The preoperative use of the IABP in high-risk patients undergoing cardiac surgery did not affect cerebral hemodynamics and was not associated with a higher incidence of neurological complications. Trial registration (NCT02143544).
- Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery The VANCS Randomized Controlled Trial(2017) HAJJAR, Ludhmila Abrahao; VINCENT, Jean Louis; GALAS, Filomena Regina Barbosa Gomes; RHODES, Andrew; LANDONI, Giovanni; OSAWA, Eduardo Atsushi; MELO, Renato Rosa; SUNDIN, Marcia Rodrigues; GRANDE, Solimar Miranda; GAIOTTO, Fabio A.; POMERANTZEFF, Pablo Maria; DALLAN, Luis Oliveira; FRANCO, Rafael Alves; NAKAMURA, Rosana Ely; LISBOA, Luiz Augusto; ALMEDIA, Juliano Pinheiro de; GERENT, Aline Muller; SOUZA, Dayenne Hianae; GAIANE, Maria Alice; FUKUSHIMA, Julia Tizue; PARK, Clarice Lee; ZAMBOLIM, Cristiane; FERREIRA, Graziela Santos Rocha; STRABELLI, Tania Mara; FERNANDES, Felipe Lourenco; CAMARA, Ligia; ZEFERINO, Suely; SANTOS, Valter Garcia; PICCIONI, Marilde Albuquerque; JATENE, Fabio Biscegli; AULER JR., Jose Otavio Costa; KALIL FILHO, RobertoBackground: Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. Methods: This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l.min(-1).m(-2)) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 mu g/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. Results: A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. Conclusions: The authors' results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.