MARCELO PARK
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
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- Ânion gap corrigido para albumina, fosfato e lactato é um bom preditor de íon gap forte em pacientes enfermos graves: estudo de coorte em nicho(2013) ZAMPIERI, Fernando Godinho; PARK, Marcelo; RANZANI, Otavio Tavares; MACIEL, Alexandre Toledo; SOUZA, Heraldo Possolo de; CRUZ NETO, Luiz Monteiro da; SILVA, Fabiano Pinheiro daOBJECTIVE: Corrected anion gap and strong ion gap are commonly used to estimate unmeasured anions. We evaluated the performance of the anion gap corrected for albumin, phosphate and lactate in predicting strong ion gap in a mixed population of critically ill patients. We hypothesized that anion gap corrected for albumin, phosphate and lactate would be a good predictor of strong ion gap, independent of the presence of metabolic acidosis. In addition, we evaluated the impact of strong ion gap at admission on hospital mortality. METHODS: We included 84 critically ill patients. Correlation and agreement between the anion gap corrected for albumin, phosphate and lactate and strong ion gap was evaluated by the Pearson correlation test, linear regression, a Bland-Altman plot and calculating interclass correlation coefficient. Two subgroup analyses were performed: one in patients with base-excess <-2mEq/L (low BE group - lBE) and the other in patients with base-excess >-2mEq/L (high BE group - hBE). A logistic regression was performed to evaluate the association between admission strong ion gap levels and hospital mortality. RESULTS: There was a very strong correlation and a good agreement between anion gap corrected for albumin, phosphate and lactate and strong ion gap in the general population (r2=0.94; bias 1.40; limits of agreement -0.75 to 3.57). Correlation was also high in the lBE group (r2=0.94) and in the hBE group (r2=0.92). High levels of strong ion gap were present in 66% of the whole population and 42% of the cases in the hBE group. Strong ion gap was not associated with hospital mortality by logistic regression. CONCLUSION: Anion gap corrected for albumin, phosphate and lactate and strong ion gap have an excellent correlation. Unmeasured anions are frequently elevated in critically ill patients with normal base-excess. However, there was no association between unmeasured anions and hospital mortality.
- Evolutive physicochemical characterization of diabetic ketoacidosis in adult patients admitted to the intensive care unit(2011) LOPES, Anselmo Dantas; MACIEL, Alexandre Toledo; PARK, MarceloPurpose: The aim of this study was to characterize the first 48-hour evolution of metabolic acidosis of adult patients with diabetic ketoacidosis admitted to the intensive care unit. Materials and Methods: We studied 9 patients retrieved from our prospective collected database, using the physicochemical approach to acid-base disturbances. Results: Mean (SD) age was 34 (13) years; mean (SD) Acute Physiology and Chronic Health Evaluation II score was 16 (10); mean (SD) blood glucose level on admission was 480 (144) mg/dL; mean (SD) pH was 7.17 (0.18); and mean (SD) standard base excess was -16.8 (7.7) mEq/L. On admission, a great part of metabolic acidosis was attributed to unmeasured anions (strong ion gap [SIG], 20 +/- 10 mEq/L), with a wide range of strong ion difference (41 +/- 10 mEq/L). During the first 48 hours of treatment, 297 +/- 180 IU of insulin and 9240 +/- 6505 mL of fluids were used. Metabolic improvement was marked by the normalization of pH, partial correction of standard base excess, and a reduction of hyperglycemia. There was a significant improvement of SIG (7.6 +/- 6.2 mEq/L) and a worsening of strong ion difference acidosis (36 +/- 5 mEq/L) in the first 24 hours, with a trend toward recuperation between 24 and 48 hours (38 +/- 6 mEq/L). Conclusion: Initial metabolic acidosis was due to SIG, and the treatment was associated with a significant decrease of SIG with an elevation of serum chloride above the normal range.
- Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study(2013) AZEVEDO, Luciano C. P.; PARK, Marcelo; SALLUH, Jorge I. F.; REA-NETO, Alvaro; SOUZA-DANTAS, Vicente C.; VARASCHIN, Pedro; OLIVEIRA, Mirella C.; TIERNO, Paulo Fernando G. M. M.; DAL-PIZZOL, Felipe; SILVA, Ulysses V. A.; KNIBEL, Marcos; NASSAR JR., Antonio P.; ALVES, Rossine A.; FERREIRA, Juliana C.; TEIXEIRA, Cassiano; REZENDE, Valeria; MARTINEZ, Amadeu; LUCIANO, Paula M.; SCHETTINO, Guilherme; SOARES, MarcioIntroduction: Contemporary information on mechanical ventilation (MV) use in emerging countries is limited. Moreover, most epidemiological studies on ventilatory support were carried out before significant developments, such as lung protective ventilation or broader application of non-invasive ventilation (NIV). We aimed to evaluate the clinical characteristics, outcomes and risk factors for hospital mortality and failure of NIV in patients requiring ventilatory support in Brazilian intensive care units (ICU). Methods: In a multicenter, prospective, cohort study, a total of 773 adult patients admitted to 45 ICUs over a two-month period requiring invasive ventilation or NIV for more than 24 hours were evaluated. Causes of ventilatory support, prior chronic health status and physiological data were assessed. Multivariate analysis was used to identifiy variables associated with hospital mortality and NIV failure. Results: Invasive MV and NIV were used as initial ventilatory support in 622 (80%) and 151 (20%) patients. Failure with subsequent intubation occurred in 54% of NIV patients. The main reasons for ventilatory support were pneumonia (27%), neurologic disorders (19%) and non-pulmonary sepsis (12%). ICU and hospital mortality rates were 34% and 42%. Using the Berlin definition, acute respiratory distress syndrome (ARDS) was diagnosed in 31% of the patients with a hospital mortality of 52%. In the multivariate analysis, age (odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01 to 1.03), comorbidities (OR, 2.30; 95% CI, 1.28 to 3.17), associated organ failures (OR, 1.12; 95% CI, 1.05 to 1.20), moderate (OR, 1.92; 95% CI, 1.10 to 3.35) to severe ARDS (OR, 2.12; 95% CI, 1.01 to 4.41), cumulative fluid balance over the first 72 h of ICU (OR, 2.44; 95% CI, 1.39 to 4.28), higher lactate (OR, 1.78; 95% CI, 1.27 to 2.50), invasive MV (OR, 2.67; 95% CI, 1.32 to 5.39) and NIV failure (OR, 3.95; 95% CI, 1.74 to 8.99) were independently associated with hospital mortality. The predictors of NIV failure were the severity of associated organ dysfunctions (OR, 1.20; 95% CI, 1.05 to 1.34), ARDS (OR, 2.31; 95% CI, 1.10 to 4.82) and positive fluid balance (OR, 2.09; 95% CI, 1.02 to 4.30). Conclusions: Current mortality of ventilated patients in Brazil is elevated. Implementation of judicious fluid therapy and a watchful use and monitoring of NIV patients are potential targets to improve outcomes in this setting.
- Determinants of Oxygen and Carbon Dioxide Transfer during Extracorporeal Membrane Oxygenation in an Experimental Model of Multiple Organ Dysfunction Syndrome(2013) PARK, Marcelo; COSTA, Eduardo Leite Vieira; MACIEL, Alexandre Toledo; SILVA, Debora Prudencio e; FRIEDRICH, Natalia; BARBOSA, Edzangela Vasconcelos Santos; HIROTA, Adriana Sayuri; SCHETTINO, Guilherme; AZEVEDO, Luciano Cesar PontesExtracorporeal membrane oxygenation (ECMO) has gained renewed interest in the treatment of respiratory failure since the advent of the modern polymethylpentene membranes. Limited information exists, however, on the performance of these membranes in terms of gas transfers during multiple organ failure (MOF). We investigated determinants of oxygen and carbon dioxide transfer as well as biochemical alterations after the circulation of blood through the circuit in a pig model under ECMO support before and after induction of MOF. A predefined sequence of blood and sweep flows was tested before and after the induction of MOF with fecal peritonitis and saline lavage lung injury. In the multivariate analysis, oxygen transfer had a positive association with blood flow (slope = 66, p<0.001) and a negative association with premembrane PaCO2 (slope = -0.96, P = 0.001) and SatO(2) (slope = 21.7, p<0.001). Carbon dioxide transfer had a positive association with blood flow (slope = 17, p<0.001), gas flow (slope = 33, p<0.001), pre-membrane PaCO2 (slope = 1.2, p<0.001) and a negative association with the hemoglobin (slope = -3.478, P = 0.042). We found an increase in pH in the baseline from 7.50[7.46,7.54] to 7.60[7.55,7.65] (p<0.001), and during the MOF from 7.19[6.92,7.32] to 7.41[7.13,7.5] (p<0.001). Likewise, the PCO2 fell in the baseline from 35 [32,39] to 25 [22,27] mmHg (p<0.001), and during the MOF from 59 [47,91] to 34 [28,45] mmHg (p<0.001). In conclusion, both oxygen and carbon dioxide transfers were significantly determined by blood flow. Oxygen transfer was modulated by the pre-membrane SatO(2) and CO2, while carbon dioxide transfer was affected by the gas flow, pre-membrane CO2 and hemoglobin.
- Análise do comportamento do sódio ao longo de 24 horas de terapia renal substitutiva(2016) ROMANO, Thiago Gomes; MARTINS, Cassia Pimenta Barufi; MENDES, Pedro Vitale; BESEN, Bruno Adler Maccagnan Pinheiro; ZAMPIERI, Fernando Godinho; PARK, MarceloABSTRACT Objective: The aim of this study was to investigate the clinical and laboratorial factors associated with serum sodium variation during continuous renal replacement therapy and to assess whether the perfect admixture formula could predict 24-hour sodium variation. Methods: Thirty-six continuous renal replacement therapy sessions of 33 patients, in which the affluent prescription was unchanged during the first 24 hours, were retrieved from a prospective collected database and then analyzed. A mixed linear model was performed to investigate the factors associated with large serum sodium variations (≥ 8mEq/L), and a Bland-Altman plot was generated to assess the agreement between the predicted and observed variations. Results: In continuous renal replacement therapy 24-hour sessions, SAPS 3 (p = 0.022) and baseline hypernatremia (p = 0.023) were statistically significant predictors of serum sodium variations ≥ 8mEq/L in univariate analysis, but only hypernatremia demonstrated an independent association (β = 0.429, p < 0.001). The perfect admixture formula for sodium prediction at 24 hours demonstrated poor agreement with the observed values. Conclusions: Hypernatremia at the time of continuous renal replacement therapy initiation is an important factor associated with clinically significant serum sodium variation. The use of 4% citrate or acid citrate dextrose - formula A 2.2% as anticoagulants was not associated with higher serum sodium variations. A mathematical prediction for the serum sodium concentration after 24 hours was not feasible.
- Extracorporeal membrane oxygenation for severe respiratory failure in adult patients: A systematic review and meta-analysis of current evidence(2013) ZAMPIERI, Fernando Godinho; MENDES, Pedro Vitale; RANZANI, Otavio T.; TANIGUCHI, Leandro Utino; AZEVEDO, Luciano Cesar Pontes; COSTA, Eduardo Leite Vieira; PARK, MarceloBackground: Extracorporeal membrane oxygenation (ECMO) for acute respiratory failure is still a matter of debate. Methods: We performed a structured search on Pubmed, EMBASE, Lilacs, and the Cochrane Library for randomized controlled trials and observational case-control studies with severity-paired patients, evaluating the use of ECMO on severe acute respiratory failure in adult patients. A random-effect model using DerSimonian and Laird method for variance estimator was performed to evaluate the effect of ECMO use on hospital mortality. Heterogeneity between studies was assessed with Cochran's Q statistic and Higgin's I-2. Results: Three studies were included on the metanalysis, comprising 353 patients in the main analysis, in which 179 patients were ECMO supported. One study was a randomized controlled trial and two were observational studies with a propensity score matching. The most common reason for acute respiratory failure was influenza H1N1 pneumonia (45%) and pneumonia (33%). ECMO was not associated with a reduction in hospital mortality (OR = 0.71; CI 95% = 0.34-1.47; P = 0.358). If alternative severity-pairing method presented by the two observational studies was included, a total of 478 cases were included, in which 228 received ECMO support. In the former analysis, ECMO had a benefit on hospital mortality (OR = 0.52; CI 95% = 0.35-0.76; P < 0.001). Conclusion: Extracorporeal membrane oxygenation benefit on hospital mortality is unclear. Results were sensitive to statistical analysis, and no definitive conclusion can be drawn from the available data. More studies are needed before the widespread use of ECMO can be recommended.
- Brazilian recommendations of mechanical ventilation 2013. Part 1(2014) CAVALCANTI, Alexandre Biasi; ISOLA, Alexandre Marini; GAMA, Ana Maria Casati; DUARTE, Antonio Carlos Magalhaes; VIANNA, Arthur; SERPA NETO, Ary; FARIAS, Augusto Manoel de Carvalho; BRAVIM, Bruno de Arruda; PINHEIRO, Bruno do Valle; MAZZA, Bruno Franco; CARVALHO, Carlos Roberto Ribeiro de; TOUFEN JUNIOR, Carlos; BARBAS, Carmen Silvia Valente; DAVID, Cid Marcos Nascimento; TANIGUCHI, Corine; MAZZA, Debora Dutra da Silveira; DRAGOSAVAC, Desanka; TOLEDO, Diogo Oliveira; COSTA, Eduardo Leite; CASER, Eliana Bemardete; SILVA, Eliezer; AMORIM, Fabio Ferreira; SADDY, Felipe; GALAS, Filomena Regina Barbosa Gomes; SILVA, Gisele Sampaio; MATOS, Gustavo Faissol Janot de; EMMERICH, Joao Claudio; VALIATTI, Jorge Luis dos Sanots; TELES, Jose Mario Vleira; VICTORINO, Josue Almeida; FERREIRA, Juliana Carvalho; PRODOMO, Luciana Passuello do Vale; HAJAR, Ludhmila Abrahao; MARTINS, Luiz Claudio; MALBOUISSON, Luiz Marcelo Sa; VARGAS, Mara Ambrosina de Oliveira; HOLANDA, Marcelo Alcantara; AMATO, Marcelo Brito Passos; PARK, Marcelo; JACOMELLI, Marcia; REIS, Marco Antonio Soares; TAVARES, Marcos; DAMASCENO, Marta Cristina Paulette; DAMASCENO, Moyzes Pinto Coelho Duarte; ASSUNCAO, Murillo Santucci Cesar; YOUSSEF, Nazah Cherif Mohamad; MESSEDER, Octavio; TEIXEIRA, Paulo Jose Zimmermann; CARUSO, Pedro; DUARTE, Pericles Almeida Delfino; EID, Raquel Caserta; RODRIGUES, Ricardo Goulart; JESUS, Rodrigo Francisco de; KAIRALLA, Ronald Adib; JUSTINO, Sandra; NEMER, Sergio Nogueira; ROMERO, Simone Barbosa; AMADO, Veronica MoreiraPerspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associacao de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in Sao Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.
- COLLOIDS IN SEPSIS: EVENLY DISTRIBUTED MOLECULES SURROUNDED BY UNEVEN QUESTIONS(2013) ZAMPIERI, Fernando Godinho; PARK, Marcelo; AZEVEDO, Luciano Cesar PontesColloids are frequently used for fluid expansion in the intensive care unit, although its use on several clinical scenarios remains unproven of any relevant clinical benefit. The purpose of this article was to carry out a narrative review regarding the safety and efficacy of colloids in patients with sepsis and septic shock, with emphasis on the most commonly used colloids, albumin and starches. Colloids are effective fluid expanders and are able to restore the hemodynamic profile with less total volume than crystalloids. These properties appear to be preserved even in patients with sepsis with increased capillary permeability. However, some colloids are associated with renal impairment and coagulation abnormalities. Starch use was associated with increased mortality in two large clinical trials. Also, starches probably have significant renal adverse effects and may be related to more need for renal replacement therapy in severe sepsis. Albumin is the only colloid that has been shown safe in patients with sepsis and that may be associated with improved outcomes on specific subpopulations. No trial so far found any robust clinical end point favoring colloid use in patients with sepsis. Because there is no proven benefit of the use of most colloids in patients with sepsis, its use should not be encouraged outside clinical trials. Albumin is the only colloid solution that has proven to be safe, and its use may be considered on hypoalbuminemic patients with sepsis. Nevertheless, there are no robust data to recommend routine albumin administration in sepsis. Starch use should be avoided in patients with sepsis because of the recent findings of a multicenter randomized study until further evidence is available.
- Adaptação metabólica diante de hipercapnia persistente aguda em pacientes submetidos à ventilação mecânica por síndrome do desconforto respiratório agudo(2016) ROMANO, Thiago Gomes; CORREIA, Mario Diego Teles; MENDES, Pedro Vitale; ZAMPIERI, Fernando Godinho; MACIEL, Alexandre Toledo; PARK, MarceloABSTRACT Objective: Hypercapnia resulting from protective ventilation in acute respiratory distress syndrome triggers metabolic pH compensation, which is not entirely characterized. We aimed to describe this metabolic compensation. Methods: The data were retrieved from a prospective collected database. Variables from patients' admission and from hypercapnia installation until the third day after installation were gathered. Forty-one patients with acute respiratory distress syndrome were analyzed, including twenty-six with persistent hypercapnia (PaCO2 > 50mmHg > 24 hours) and 15 non-hypercapnic (control group). An acid-base quantitative physicochemical approach was used for the analysis. Results: The mean ages in the hypercapnic and control groups were 48 ± 18 years and 44 ± 14 years, respectively. After the induction of hypercapnia, pH markedly decreased and gradually improved in the ensuing 72 hours, consistent with increases in the standard base excess. The metabolic acid-base adaptation occurred because of decreases in the serum lactate and strong ion gap and increases in the inorganic apparent strong ion difference. Furthermore, the elevation in the inorganic apparent strong ion difference occurred due to slight increases in serum sodium, magnesium, potassium and calcium. Serum chloride did not decrease for up to 72 hours after the initiation of hypercapnia. Conclusion: In this explanatory study, the results indicate that metabolic acid-base adaptation, which is triggered by acute persistent hypercapnia in patients with acute respiratory distress syndrome, is complex. Furthermore, further rapid increases in the standard base excess of hypercapnic patients involve decreases in serum lactate and unmeasured anions and increases in the inorganic apparent strong ion difference by means of slight increases in serum sodium, magnesium, calcium, and potassium. Serum chloride is not reduced.
- Brazilian recommendations of mechanical ventilation 2013. Part 2(2014) CAVALCANTI, Alexandre Biasi; ISOLA, Alexandre Marini; GAMA, Ana Maria Casati; DUARTE, Antonio Carlos Magalhaes; VIANNA, Arthur; SERPA NETO, Ary; FARIAS, Augusto Manoel de Carvalho; BRAVIM, Bruno de Arruda; PINHEIRO, Bruno do Valle; MAZZA, Bruno Franco; CARVALHO, Carlos Roberto Ribeiro de; TOUFEN JUNIOR, Carlos; BARBAS, Carmen Silvia Valente; DAVID, Cid Marcos Nascimento; TANIGUCHI, Corine; MAZZA, Debora Dutra da Silveira; DRAGOSAVAC, Desanka; TOLEDO, Diogo Oliveira; COSTA, Eduardo Leite; CASER, Eliana Bernardete; SILVA, Eliezer; AMORIM, Fabio Ferreira; SADDY, Felipe; GALAS, Filomena Regina Barbosa Gomes; SILVA, Gisele Sampaio; MATOS, Gustavo Faissol Janot de; EMMERICH, Joao Claudio; VALIATTI, Jorge Luis dos Sanots; TELES, Jose Mario Meira; VICTORINO, Josue Almeida; FERREIRA, Juliana Carvalho; PRODOMO, Luciana Passuello do Vale; HAJJAR, Ludhmila Abrahao; MARTINS, Luiz Claudio; MALBOUISSON, Luiz Marcelo Sa; VARGAS, Mara Ambrosina de Oliveira; HOLANDA, Marcelo Alcantara; AMATO, Marcelo Brito Passos; PARK, Marcelo; JACOMELLI, Marcia; REIS, Marco Antonio Soares; TAVARES, Marcos; DAMASCENO, Marta Cristina Paulette; DAMASCENO, Moyzes Pinto Coelho Duarte; ASSUNCAO, Murillo Santucci Cesar; YOUSSEF, Nazah Cherif Mohamad; MESSEDER, Octavio; TEIXEIRA, Paulo Jose Zimmermann; CARUSO, Pedro; DUARTE, Pericles Almeida Delfino; EID, Raquel Caserta; RODRIGUES, Ricardo Goulart; JESUS, Rodrigo Francisco de; KAIRALLA, Ronaldo Adib; JUSTINO, Sandra; NEMER, Sergio Nogueira; ROMERO, Simone Barbosa; AMADO, Veronica MoreiraPerspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associacao de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in Sao Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.