JULIANO PINHEIRO DE ALMEIDA
Projetos de Pesquisa
Unidades Organizacionais
Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/08 - Laboratório de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina
LIM/08 - Laboratório de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina
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Resultados de Busca
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- Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis(2016) DOCHERTY, Annemarie B.; O'DONNELL, Rob; BRUNSKILL, Susan; TRIVELLA, Marialena; DOREE, Carolyn; HOLST, Lars; PARKER, Martyn; GREGERSEN, Merete; ALMEIDA, Juliano Pinheiro de; WALSH, Timothy S.; STANWORTH, Simon J.OBJECTIVE To compare patient outcomes of restrictive versus liberal blood transfusion strategies in patients with cardiovascular disease not undergoing cardiac surgery. DESIGN Systematic review and meta-analysis. DATA SOURCES Randomised controlled trials involving a threshold for red blood cell transfusion in hospital. We searched (to 2 November 2015) CENTRAL, Medline, Embase, CINAHL, PubMed, LILACS, NHSBT Transfusion Evidence Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, ISRCTN Register, and EU Clinical Trials Register. Authors were contacted for data whenever possible. TRIAL SELECTION Published and unpublished randomised controlled trials comparing a restrictive with liberal transfusion threshold and that included patients with cardiovascular disease. DATA EXTRACTION AND SYNTHESIS Data extraction was completed in duplicate. Risk of bias was assessed using Cochrane methods. Relative risk ratios with 95% confidence intervals were presented in all meta-analyses. Mantel-Haenszel random effects models were used to pool risk ratios. MAIN OUTCOME MEASURES 30 day mortality, and cardiovascular events. RESULTS 41 trials were identified; of these, seven included data on patients with cardiovascular disease. Data from a further four trials enrolling patients with cardiovascular disease were obtained from the authors. In total, 11 trials enrolling patients with cardiovascular disease (n= 3033) were included for meta-analysis (restrictive transfusion, n= 1514 patients; liberal transfusion, n= 1519). The pooled risk ratio for the association between transfusion thresholds and 30 day mortality was 1.15 (95% confidence interval 0.88 to 1.50, P= 0.50), with little heterogeneity (I-2= 14%). The risk of acute coronary syndrome in patients managed with restrictive compared with liberal transfusion was increased (nine trials; risk ratio 1.78, 95% confidence interval 1.18 to 2.70, P= 0.01, I-2= 0%). CONCLUSIONS The results show that it may not be safe to use a restrictive transfusion threshold of less than 80 g/L in patients with ongoing acute coronary syndrome or chronic cardiovascular disease. Effects on mortality and other outcomes are uncertain. These data support the use of a more liberal transfusion threshold (> 80 g/L) for patients with both acute and chronic cardiovascular disease until adequately powered high quality randomised trials have been undertaken in patients with cardiovascular disease.
- Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review(2016) OSAWA, Eduardo A.; RHODES, Andrew; LANDONI, Giovanni; GALAS, Filomena R. B. G.; FUKUSHIMA, Julia T.; PARK, Clarice H. L.; ALMEIDA, Juliano P.; NAKAMURA, Rosana E.; STRABELLI, Tania M. V.; PILEGGI, Brunna; LEME, Alcino C.; FOMINSKIY, Evgeny; SAKR, Yasser; LIMA, Marta; FRANCO, Rafael A.; CHAN, Raquel P. C.; PICCIONI, Marilde A.; MENDES, Priscilla; MENEZES, Suellen R.; BRUNO, Tatiana; GAIOTTO, Fabio A.; LISBOA, Luiz A.; DALLAN, Luiz A. O.; HUEB, Alexandre C.; POMERANTZEFF, Pablo M.; KALIL FILHO, Roberto; JATENE, Fabio B.; AULER JUNIOR, Jose Otavio Costa; HAJJAR, Ludhmila A.Objectives: To evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery. Design: A prospective randomized controlled trial and an updated metaanalysis of randomized trials published from inception up to May 1, 2015. Setting: Surgical ICU within a tertiary referral university-affiliated teaching hospital. Patients: One hundred twenty-six high-risk patients undergoing coronary artery bypass surgery or valve repair. Interventions: Patients were randomized to a cardiac output-guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64). In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m(2) was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU. Measurements and Main Results: The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed therapy group received a greater median (interquartile range) volume of IV fluids than the usual care group (1,000 [625-1,500] vs 500 [500-1,000] mL; p < 0.001], with no differences in the administration of either inotropes or RBC transfusions. The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037). The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome (6.5% vs 26.6%; p = 0.002). We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3-4] vs 5 [4-7] d; p < 0.001) and hospital length of stay (9 [8-16] vs 12 [9-22] d; p = 0.049) in the goal-directed therapy compared with the usual care group. There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410 [11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26-0.63]; p < 0.0001) and decreased the hospital length of stay (mean difference, -5.44 d; 95% CI, -9.28 to -1.60; p = 0.006) with no difference in postoperative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio, 0.61 (95% CI, 0.26-1.47), and p = 0.27. Conclusions: Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing cardiac surgery.