JOAO MANOEL DA SILVA JUNIOR
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina - Médico
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/08 - Laboratório de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/08 - Laboratório de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina
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- The effects of acute kidney injury in a multicenter cohort of high-risk surgical patients(2021) KATAYAMA, Henrique Tadashi; GOMES, Brenno Cardoso; LOBO, Suzana Margareth Ajeje; CHAVES, Renato Carneiro de Freitas; CORREA, Thiago Domingos; ASSUNCAO, Murillo Santucci Cesar; SERPA NETO, Ary; MALBOUISSON, Luiz Marcelo Sa; SILVA, Joao ManoelBackground and objectives Patients who develop post-operative acute kidney injury (AKI) have a poor prognosis, especially when undergoing high-risk surgery. Therefore, the objective of this study was to evaluate the outcome of patients with AKI acquired after non-cardiac surgery and the possible risk factors for this complication. Methods A multicenter, prospective cohort study with patients admitted to intensive care units (ICUs) after non-cardiac surgery was conducted to assess whether they developed AKI. The patients who developed AKI were then compared to non-AKI patients. Results A total of 29 ICUs participated, of which 904 high-risk surgical patients were involved in the study. The occurrence of AKI in the post-operative period was 15.8%, and the mortality rate of post-operative AKI patients at 28 days was 27.6%. AKI was strongly associated with 28-day mortality (OR = 2.91; 95% CI 1.51-5.62; p = 0.001), and a higher length of ICU and hospital stay (p < 0.001). Independent factors for the risk of developing AKI were pre-operative anemia (OR = 7.01; 95% CI 1.69-29.07), elective surgery (OR = 0.45; 95% CI 0.21-0.97), SAPS 3 (OR = 1.04; 95% CI 1.02-1.06), post-operative vasopressor use (OR = 2.47; 95% CI 1.34-4.55), post-operative infection (OR = 8.82; 95% CI 2.43-32.05) and the need for reoperation (OR= 7.15; 95% CI 2.58-19.79). Conclusion AKI was associated with the risk of death in surgical patients and those with anemia before surgery, who had a higher SAPS 3, needed a post-operative vasopressor, or had a post-operative infection or needed reoperation were more likely to develop AKI post-operatively.
- Trends in perioperative practices of high-risk surgical patients over a 10-year interval(2023) GOMES, Brenno Cardoso; LOBO, Suzana Margareth Ajeje; MALBOUISSON, Luiz Marcelo Sa; CHAVES, Renato Carneiro de Freitas; CORREA, Thiago Domingos; AMENDOLA, Cristina Prata; SILVA JUNIOR, Joao Manoel; BraSIS Res GrpIntroductionIn Brazil, data show an important decrease in morbi-mortality of high-risk surgical patients over a 10-year high. The objective of this post-hoc study was to evaluate the mechanism explaining this trend in high-risk surgical patients admitted to Brazilian ICUs in two large Brazilian multicenter cohort studies performed 10 years apart.MethodsThe patients included in the 2 cohorts studies published in 2008 and 2018 were compared after a (1:1) propensity score matching. Patients included were adults who underwent surgeries and admitted to the ICU afterwards.ResultsAfter matching, 704 patients were analyzed. Compared to the 2018 cohort, 2008 cohort had more postoperative infections (OR 13.4; 95%CI 6.1-29.3) and cardiovascular complications (OR 1.5; 95%CI 1.0-2.2), as well as a lower survival ICU stay (HR = 2.39, 95% CI: 1.36-4.20) and hospital stay (HR = 1.64, 95% CI: 1.03-2.62). In addition, by verifying factors strongly associated with hospital mortality, it was found that the risk of death correlated with higher intraoperative fluid balance (OR = 1.03, 95% CI 1.01-1.06), higher creatinine (OR = 1.31, 95% CI 1.1-1.56), and intraoperative blood transfusion (OR = 2.32, 95% CI 1.35-4.0). By increasing the mean arterial pressure, according to the limits of sample values from 43 mmHg to 118 mmHg, the risk of death decreased (OR = 0.97, 95% CI 0.95-0.98). The 2008 cohort had higher fluid balance, postoperative creatinine, and volume of intraoperative blood transfused and lower mean blood pressure at ICU admission and temperature at the end of surgery.ConclusionIn this sample of ICUs in Brazil, high-risk surgical patients still have a high rate of complications, but with improvement over a period of 10 years. There were changes in the management of these patients over time.
conferenceObject A PRAGMATIC MULTI-CENTRE TRIAL ON INTRAOPERATIVE FLUID MANAGEMENT USING PULSE PRESSURE VARIATION IN HIGH-RISK PATIENTS(2014) MALBOUISSON, L. M. S.; SILVA JR., J. M.; CARMONA, M. J. C.; ASSUNCAO, M. C. S.; VALIATTI, J. L.; LOPES, M. R.; SIMOES, C. M.; MICHARD, E.; AULER JR., J. O. C.- A pragmatic multi-center trial of goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery(2017) MALBOUISSON, Luiz Marcelo Sa; SILVA JR., Joao Manoel; CARMONA, Maria Jose Carvalho; LOPES, Marcel Rezende; ASSUNCAO, Murilo Santucci; VALIATTI, Jorge Luis dos Santos; SIMOES, Claudia Marques; AULER JR., Jose Otavio CostaBackground: 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.
- Ventilation practices in burn patients-an international prospective observational cohort study(2021) GLAS, Gerie J.; HORN, Janneke; HOLLMANN, Markus W.; PRECKEL, Benedikt; COLPAERT, Kirsten; MALBRAIN, Manu; NETO, Ary Serpa; ASEHNOUNE, Karim; ABREU, Marcello Gamma de; MARTIN-LOECHES, Ignacio; PELOSI, Paolo; SJOBERG, Folke; BINNEKADE, Jan M.; CLEFFKEN, Berry; JUFFERMANS, Nicole P.; KNAPE, Paul; LOEF, Bert G.; MACKIE, David P.; ENKHBAATAR, Perenlei; DEPETRIS, Nadia; PERNER, Anders; HERRERO, Eva; CACHAFEIRO, Lucia; JESCHKE, Marc; LIPMAN, Jeffrey; LEGRAND, Matthieu; HORTER, Johannes; LAVRENTIEVA, Athina; KAZEMI, Alex; GUTTORMSEN, Anne Berit; HUSS, Frederik; KOL, Mark; WONG, Helen; STARR, Therese; CROP, Luc De; OLIVEIRA FILHO, Wilson de; SILVA JUNIOR, Joao Manoel; GRION, Cintia M. C.; BURNETT, Marjorie; MONDRUP, Frederik; RAVAT, Francois; FONTAINE, Mathieu; FLOCH, Renan Le; JEANNE, Mathieu; BACUS, Morgane; CHAUSSARD, Maite; LEHNHARDT, Marcus; MIKHAIL, Bassem Daniel; GILLE, Jochen; SHARKEY, Aidan; TROMMEL, Nicole; REIDINGA, Auke C.; VIELEERS, Nadine; TILSLEY, Anna; ONARHEIM, Henning; BOUZA, Maria Teresa; AGRIFOGLIO, Alexander; FREDEN, Filip; PALMIERI, Tina; PAINTING, Lynda E.; SCHULTZ, Marcus J.Background: It is unknown whether lung-protective ventilation is applied in burn patients and whether they benefit from it. This study aimed to determine ventilation practices in burn intensive care units (ICUs) and investigate the association between lung-protective ventilation and the number of ventilator-free days and alive at day 28 (VFD-28). Methods: This is an international prospective observational cohort study including adult burn patients requiring mechanical ventilation. Low tidal volume (V-T) was defined as V-T <= 8 mL/kg predicted body weight (PBW). Levels of positive end-expiratory pressure (PEEP) and maximum airway pressures were collected. The association between V-T and VFD-28 was analyzed using a competing risk model. Ventilation settings were presented for all patients, focusing on the first day of ventilation. We also compared ventilation settings between patients with and without inhalation trauma. Results: A total of 160 patients from 28 ICUs in 16 countries were included. Low V-T was used in 74% of patients, median V-T size was 7.3 [interquartile range (IQR) 6.2-8.3] mL/kg PBW and did not differ between patients with and without inhalation trauma (p= 0.58). Median VFD-28 was 17 (IQR 0-26), without a difference between ventilation with low or high V-T (p= 0.98). All patients were ventilated with PEEP levels >= 5 cmH(2)O; 80% of patients had maximum airway pressures <30 cmH(2)O. Conclusion: In this international cohort study we found that lung-protective ventilation is used in the majority of burn patients, irrespective of the presence of inhalation trauma. Use of low V-T was not associated with a reduction in VFD-28.
- Referral to immediate postoperative care in an intensive care unit from the perspective of anesthesiologists, surgeons, and intensive care physicians: a cross-sectional questionnaire(2021) SILVA JR., Joao Manoel; KATAYAMA, Henrique Tadashi; LOPES, Felipe Manuel Vasconcellos; TOLEDO, Diogo Oliveira; AMENDOLA, Cristina Prata; OLIVEIRA, Fernanda dos Santos; ANDRAUS, Leusi Magda Romano; CARMONA, Maria Jose C.; LOBO, Suzana Margareth; MALBOUISSON, Luiz Marcelo SaIntroduction and objective: Due to the high cost and insufficient offer, the request for Intensive Care (ICU) beds for postoperative recovery needs adequate criteria. Therefore, we studied the characteristics of patients referred to postoperative care at an ICU from the perspective of anesthesiologists, surgeons, and intensive care physicians. Methods: A questionnaire on referrals to postoperative intensive care was applied to physicians at congresses in Brazil. Anesthesiologists, surgeons, and intensive care physicians who agreed to fill out the questionnaire were included. The questionnaire consisted of hypothetical clinical scenarios and cases for participants to choose which would be the priority for referral to the ICU. Results: 360 physicians participated in the study, with median time of 10 (5-18) years after graduation. Of the interviewees, 36.4% were anesthesiologists, 30.0% surgeons, and 33.6% intensive care physicians. We found that anesthesiologists were more conservative, and surgeons less & nbsp;conservative in ICU referrals. As to patients with risk of bleeding, 75.0% of the surgeons would refer them to the ICU, in contrast with 52.1% of the intensive care physicians, and 43.5% of the anesthesiologists (p < 0.001). As to elderly persons with limited reserve, 62.0% of the surgeons would refer them to the ICU, in contrast with 47.1% of the intensive care physicians, and 22.1% of the anesthesiologists (p < 0.001). As to patients with risk of respiratory complications, 64.5% of the surgeons would recommend the ICU, versus 43.0% of the intensive care physicians, and 32.1% of the anesthesiologists (p < 0.001). Intensive care physicians classified priorities better in indicating ICU, and the main risk indicator was the ASA physical status in all specialties (p < 0.001). There was no agreement among the specialties and surgeries on prioritizing post-operative intensive care. Conclusion: Anesthesiologists, surgeons, and intensive care physicians presented different per-spectives on postoperative referral to the ICU. (c) 2021 Sociedade Brasileira de Anestesiologia.
- Metabolic Acidosis Assessment in High-Fisk Surgeries: Prognostic Importance(2016) SILVA JR., Joao Manoel; OLIVEIRA, Amanda Maria Ribas Rosa de; NOGUEIRA, Fernando Augusto Mendes; VIANNA, Pedro M. M.; AMENDOLA, Cristina Prata; CARMONA, Maria Jose Carvalho; MALBOUISSON, Luiz M. SaBACKGROUND: 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 (Cl) = 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.
- A sobrecarga intravenosa de fluidos e sódio pode contribuir para a menor infusão de nutrição enteral em pacientes críticos(2019) DOCK-NASCIMENTO, Diana Borges; ARANTES, Suzana Souza; SILVA JR, João Manoel; AGUILAR-NASCIMENTO, José Eduardo deABSTRACT Objective: To evaluate the effects of intravenous infusion of fluids and sodium on the first day of admission on infusion of enteral nutrition in the first 5 days in intensive care patients. Methods: A prospective cohort study was conducted with critical nonsurgical patients admitted for at least 5 days who were on mechanical ventilation and receiving enteral nutrition. The amount of intravenous fluids and sodium infused on the first day and the volume of enteral nutrition infused in the first 5 days were investigated. The volume of intravenous fluids > 35mL/kg or ≤ 35mL/kg of body weight and sodium (above or below the 25th percentile) infused on the first day was compared with infused enteral nutrition. Results: A total of 86 patients were studied, with a mean (± standard deviation) of 65 ± 17 years, of which 54.7% were female. On the first day, 3,393.7 ± 1,417.0mL of fluid (48.2 ± 23.0mL/kg) and 12.2 ± 5.1g of sodium were administered. Fifty-eight (67.4%) patients received more than 35mL/kg of fluids. In 5 days, 67 ± 19.8% (2,993.8 ± 1,324.4mL) of the prescribed enteral nutrition was received. Patients who received > 35mL/kg of intravenous fluids also received less enteral nutrition in 5 days (2,781.4 ± 1,337.9 versus 3,433.6 ± 1,202.2mL; p = 0.03) versus those who received ≤ 35mL/kg. Patients with intravenous sodium infusion above the 25th percentile (≥ 8.73g) on the first day received less enteral nutrition volume in 5 days (2,827.2 ± 1,398.0 versus 3,509.3 ± 911.9mL; p = 0.02). Conclusion: The results of this study support the assumption that the administration of intravenous fluids > 35mL/kg and sodium ≥ 8.73g on the first day of hospitalization may contribute to the lower infusion of enteral nutrition in critically ill patients.
conferenceObject GOAL-DIRECTED THERAPY DOES NOT REVERSE AKI IN CRITICALLY ILL PATIENTS BUT DECREASES MORTALITY.(2014) AMENDOLA, Cristina; SILVA, Joao; CARVALHO, Taisa; LIMA, Emerson; BURDMANN, Emmanuel; MALBOUISSON, Luiz; LOBO, SuzanaconferenceObject Meropenem extended infusion versus intermittent infusion against nosocomial MIC 4 mg/L strains to guarantee drug effectiveness by PK/PD approach in burn patients at the earlier period of septic shock(2021) MORALES JR., R.; KUPA, L. V. K.; VIANNA, K. B.; GARCIA, C. M.; SANTOS, V. J.; CAMPOS, E. V.; SILVA JR., J. M.; SILVA JR., E. M.; OLIVEIRA, T. C.; GOMEZ, D. S.; SANTOS, S. R. C. J.