LUDHMILA ABRAHAO HAJJAR
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Clínica Médica, Faculdade de Medicina - Docente
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
LIM/08 - Laboratório de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
LIM/08 - Laboratório de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina
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article 0 Citação(ões) na Scopus Dobutamine administration in patients after cardiac surgery: beneficial or harmful?(2011) HAJJAR, Ludhmila A.; FUKUSHIMA, Julia T.; OSAWA, Eduardo; ALMEIDA, Juliano P.; GALAS, Filomena R. B. G.- Current use of inotropes in circulatory shock(2021) SCHEEREN, Thomas W. L.; BAKKER, Jan; KAUFMANN, Thomas; ANNANE, Djillali; ASFAR, Pierre; BOERMA, E. Christiaan; CECCONI, Maurizio; CHEW, Michelle S.; CHOLLEY, Bernard; CRONHJORT, Maria; BACKER, Daniel De; DUBIN, Arnaldo; DUENSER, Martin W.; DURANTEAU, Jacques; GORDON, Anthony C.; HAJJAR, Ludhmila A.; HAMZAOUI, Olfa; HERNANDEZ, Glenn; EDUL, Vanina Kanoore; KOSTER, Geert; LANDONI, Giovanni; LEONE, Marc; LEVY, Bruno; MARTIN, Claude; MEBAZAA, Alexandre; MONNET, Xavier; MORELLI, Andrea; PAYEN, Didier; PEARSE, Rupert M.; PINSKY, Michael R.; RADERMACHER, Peter; REUTER, Daniel A.; SAKR, Yasser; SANDER, Michael; SAUGEL, Bernd; SINGER, Mervyn; SQUARA, Pierre; VIEILLARD-BARON, Antoine; VIGNON, Philippe; VINCENT, Jean-Louis; HORST, Iwan C. C. van der; VISTISEN, Simon T.; TEBOUL, Jean-LouisBackground: Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock. Methods: From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions. Results: A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81-90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement). Conclusion: Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.
- 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.
- Is there still a place for transcranial Doppler in patients with IABP?(2020) CALDAS, Juliana R.; PANERAI, Ronney B.; PASSOS, Rogerio; HAJJAR, Ludhmila A.
- Haemodynamic monitoring in the perioperative setting(2023) QUINTAO, Vinicius Caldeira; JR, Armindo Jreige; RIZK, Stephanie Itala; HAJJAR, Ludhmila AbrahaoPurpose of reviewThe aim of this study was to review the role of haemodynamic monitoring in the perioperative setting, highlighting who are the patients who most benefit, to describe the type of devices, to analyse the scientific evidence and to suggest algorithms of haemodynamic care in high-risk surgical patients.Recent findingsIn the last 50 years, many advances have contributed to better understand cardiovascular physiology at bedside, and haemodynamic monitoring has moved from invasive methods to minimally invasive and noninvasive devices. Randomized clinical trials have shown benefits of perioperative haemodynamic therapy to improve outcomes in high-risk surgical patients. A multimodal approach is purposed in the perioperative setting to optimize haemodynamic parameters, involving clinical analysis at bedside, the use of dynamic tests for fluid responsiveness and integration of variables, including cardiac output, systolic volume, tissue oxygen markers and echocardiographic measures.In this review, we summarize the benefits of haemodynamic monitoring, the type of devices with advantages and disadvantages, the scientific evidence supporting perioperative haemodynamic therapy, and we suggest a multimodal approach to improve patients' care.
- Vasopressin in septic shock: an individual patient data meta-analysis of randomised controlled trials(2019) NAGENDRAN, Myura; RUSSELL, James A.; WALLEY, Keith R.; BRETT, Stephen J.; PERKINS, Gavin D.; HAJJAR, Ludhmila; MASON, Alexina J.; ASHBY, Deborah; GORDON, Anthony C.PurposeWe performed an individual patient data meta-analysis to investigate the possible benefits and harms of vasopressin therapy in adults with septic shock both overall and in pre-defined subgroups.MethodsOur pre-specified study protocol is published on PROSPERO, CRD42017071698. We identified randomised clinical trials up to January 2019 investigating vasopressin therapy versus any other vasoactive comparator in adults with septic shock. Individual patient data from each trial were compiled. Conventional two-stage meta-analyses were performed as well as one-stage regression models with single treatment covariate interactions for subgroup analyses.ResultsFour trials were included with a total of 1453 patients. For the primary outcomes, there was no effect of vasopressin on 28-day mortality [relative risk (RR) 0.98, 95% CI 0.86-1.12] or serious adverse events (RR 1.02, 95% CI 0.82-1.26). Vasopressin led to more digital ischaemia [absolute risk difference (ARD) 1.7%, 95% CI 0.3%-3.2%] but fewer arrhythmias (ARD -2.8%, 95% CI -0.2% to -5.3%). Mesenteric ischaemia and acute coronary syndrome events were similar between groups. Vasopressin reduced the requirement for renal replacement therapy (RRT) (RR 0.86, 95% CI 0.74-0.99), but this finding was not robust to sensitivity analyses. There were no statistically significant interactions in the pre-defined subgroups (baseline kidney injury severity, baseline lactate, baseline norepinephrine requirement and time to study inclusion).ConclusionsVasopressin therapy in septic shock had no effect on 28-day mortality although the confidence intervals are wide. It appears safe but with a different side effect profile from norepinephrine. The finding on reduced RRT should be interpreted cautiously. Future trials should focus on long-term outcomes in select patient groups as well as incorporating cost effectiveness analyses regarding possible reduced RRT use.
- Vasopressin Versus Norepinephrine for the Management of Septic Shock in Cancer Patients: The VANCS II Randomized Clinical Trial*(2019) HAJJAR, Ludhmila Abrahao; ZAMBOLIM, Cristiane; BELLETTI, Alessandro; ALMEIDA, Juliano Pinheiro de; GORDON, Anthony C.; OLIVEIRA, Gisele; PARK, Clarice Hyesuk Lee; FUKUSHIMA, Julia Tizue; RIZK, Stephanie Itala; SZELES, Tais Felix; SANTOS NETO, Nestor Cordeiro dos; KALIL FILHO, Roberto; GALAS, Filomena Regina Barbosa Gomes; LANDONI, GiovanniObjectives: Previous trials suggest that vasopressin may improve outcomes in patients with vasodilatory shock. The aim of this study was to evaluate whether vasopressin could be superior to norepinephrine to improve outcomes in cancer patients with septic shock. Design: Single-center, randomized, double-blind clinical trial, and meta-analysis of randomized trials. Setting: ICU of a tertiary care hospital. Patients: Two-hundred fifty patients 18 years old or older with cancer and septic shock. Interventions: Patients were assigned to either vasopressin or norepinephrine as first-line vasopressor therapy. An updated meta-analysis was also conducted including randomized trials published until October 2018. Measurements and Main Results: The primary outcome was all-cause mortality at 28 days after randomization. Prespecified secondary outcomes included 90-days all-cause mortality rate; number of days alive and free of advanced organ support at day 28; and Sequential Organ Failure Assessment score 24 hours and 96 hours after randomization. We also measure the prevalence of adverse effects in 28 days. A total of 250 patients were randomized. The primary outcome was observed in 71 patients (56.8%) in the vasopressin group and 66 patients (52.8%) in the norepinephrine group (p = 0.52). There were no significant differences in 90-day mortality (90 patients [72.0%] and 94 patients [75.2%], respectively; p = 0.56), number of days alive and free of advanced organ support, adverse events, or Sequential Organ Failure Assessment score. Conclusions: In cancer patients with septic shock, vasopressin as first-line vasopressor therapy was not superior to norepinephrine in reducing 28-day mortality rate.
article Dobutamine administration in patients after cardiac surgery: beneficial or harmful? response(2011) HAJJAR, Ludhmila A.; FUKUSHIMA, Julia T.; OSAWA, Eduardo; ALMEIDA, Juliano P.; GALAS, Filomena R. B. G.- Alternatives to the Swan-Ganz catheter(2018) BACKER, Daniel De; BAKKER, Jan; CECCONI, Maurizio; HAJJAR, Ludhmila; LIU, Da Wei; LOBO, Suzanna; MONNET, Xavier; MORELLI, Andrea; MYATRA, Sheila Neinan; PEREL, Azriel; PINSKY, Michael R.; SAUGEL, Bernd; TEBOUL, Jean-Louis; VIEILLARD-BARON, Antoine; VINCENT, Jean-LouisWhile the pulmonary artery catheter (PAC) is still interesting in specific situations, there are many alternatives. A group of experts from different backgrounds discusses their respective interests and limitations of the various techniques and related measured variables. The goal of this review is to highlight the conditions in which the alternative devices will suffice and when they will not or when these alternative techniques can provide information not available with PAC. The panel concluded that it is useful to combine different techniques instead of relying on a single one and to adapt the ""package"" of interventions to the condition of the patient. As a first step, the clinical and biologic signs should be used to identify patients with impaired tissue perfusion. Whenever available, echocardiography should be performed as it provides a rapid and comprehensive hemodynamic evaluation. If the patient responds rapidly to therapy, either no additional monitoring or pulse wave analysis (allowing continuous monitoring in case potential degradation is anticipated) can be applied. If the patient does not rapidly respond to therapy or complex hemodynamic alterations are observed, pulse wave analysis coupled with TPTD is suggested.