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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- Factors associated with renal Doppler resistive index in critically ill patients: a prospective cohort study(2019) OLIVEIRA, Raphael A. G.; MENDES, Pedro V.; PARK, Marcelo; TANIGUCHI, Leandro U.BackgroundThe renal Doppler resistive index (renal RI) is a noninvasive tool that has been used to assess renal perfusion in the intensive care unit (ICU) setting. However, many parameters have been described as influential on the values of renal RI. Therefore, we proposed this study to evaluate the variables that could impact renal RI in critically ill patients.MethodsA prospective observational study was performed in a 14-bed medical-surgical adult ICU. All consecutive patients admitted to the ICU during the study period were evaluated for eligibility. Renal RI was performed daily until the third day after ICU admission, death, or renal replacement therapy (RRT) requirement. Clinical and blood test data were collected throughout this period. Acute kidney injury (AKI) reversibility was categorized as transient (normalization of renal function within 3days of AKI onset) or persistent (non-resolution of AKI within 3days of onset or need for RRT). A linear mixed model was applied to evaluate the factors that could influence renal RI.ResultsEighty-three consecutive patients were included. Of these, 65% were male and 50.6% were medical admissions. Mean SAPS 3 was 4716. Renal RI was significantly different between no-AKI (0.64 +/- 0.06), transient AKI (0.64 +/- 0.07), and persistent AKI groups (0.70 +/- 0.08, p<0.01). Variables associated with renal RI variations were mean arterial pressure, lactate, age, and persistent AKI (p<0.05). No association between serum chloride and renal RI was observed p=0.868).Conclusions Mean arterial pressure, lactate, age, and type of AKI might influence renal RI in critically ill patients.
- Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients: Systematic Review and Meta-Analysis(2019) BESEN, Bruno Adler Maccagnan Pinheiro; ROMANO, Thiago Gomes; MENDES, Pedro Vitale; GALLO, Cesar Albuquerque; ZAMPIERI, Fernando Godinho; NASSAR JR., Antonio Paulo; PARK, MarceloObjective: Early initiation of renal replacement therapy (RRT) effect on survival and renal recovery of critically ill patients is still uncertain. We aimed to systematically review current evidence comparing outcomes of early versus late initiation of RRT in critically ill patients. Methods: We searched the Medline (via Pubmed), LILACS, Science Direct, and CENTRAL databases from inception until November 2016 for randomized clinical trials (RCTs) or observational studies comparing early versus late initiation of RRT in critically ill patients. The primary outcome was mortality. Duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and renal function recovery were secondary outcomes. Meta-analysis and trial sequential analysis (TSA) were used for the primary outcome. Results: Sixty-two studies were retrieved and analyzed, including 11 RCTs. There was no difference in mortality between early and late initiation of RRT among RCTs (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.52-1.19; I-2 = 63.1%). Trial sequential analysis of mortality across all RCTs achieved futility boundaries at both 1% and 5% type I error rates, although a subgroup analysis of studies including only acute kidney injury patients was not conclusive. There was also no difference in time on mechanical ventilation, ICU and hospital LOS, or renal recovery among studies. Early initiation of RRT was associated with reduced mortality among prospective (OR = 0.69; 95% CI: 0.49-0.96; I-2 = 85.9%) and retrospective (OR = 0.61; 95% CI: 0.41-0.92; I-2 = 90.9%) observational studies, both with substantial heterogeneity. However, subgroup analysis excluding low-quality observational studies did not achieve statistical significance. Conclusion: Pooled analysis of randomized trials indicates early initiation of RRT is not associated with lower mortality rates. The potential benefit of reduced mortality associated with early initiation of RRT was limited to low-quality observational studies.
- Oxigenação por membrana extracorpórea para síndrome do desconforto respiratório agudo grave em pacientes adultos: revisão sistemática e metanálise(2019) MENDES, Pedro Vitale; MELRO, Livia Maria Garcia; LI, Ho Yeh; JOELSONS, Daniel; ZIGAIB, Rogerio; RIBEIRO, José Mauro da Fonseca Pestana; BESEN, Bruno Adler Maccagnan Pinheiro; PARK, MarceloABSTRACT Objective: The evidence of improved survival with the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome is still uncertain. Methods: This systematic review and meta-analysis was registered in the PROSPERO database with the number CRD-42018098618. We performed a structured search of Medline, Lilacs, and ScienceDirect for randomized controlled trials evaluating the use of ECMO associated with (ultra)protective mechanical ventilation for severe acute respiratory failure in adult patients. We used the Cochrane risk of bias tool to evaluate the quality of the evidence. Our primary objective was to evaluate the effect of ECMO on the last reported mortality. Secondary outcomes were treatment failure, hospital length of stay and the need for renal replacement therapy in both groups. Results: Two randomized controlled studies were included in the meta-analysis, comprising 429 patients, of whom 214 were supported with ECMO. The most common reason for acute respiratory failure was pneumonia (60% - 65%). Respiratory ECMO support was associated with a reduction in last reported mortality and treatment failure with risk ratios (RR: 0.76; 95%CI 0.61 - 0.95 and RR: 0.68; 95%CI 0.55 - 0.85, respectively). Extracorporeal membrane oxygenation reduced the need for renal replacement therapy, with a RR of 0.88 (95%CI 0.77 - 0.99). Intensive care unit and hospital lengths of stay were longer in ECMO-supported patients, with an additional P50th 14.84 (P25th - P75th: 12.49 - 17.18) and P50th 29.80 (P25th - P75th: 26.04 - 33.56] days, respectively. Conclusion: Respiratory ECMO support in severe acute respiratory distress syndrome patients is associated with a reduced mortality rate and a reduced need for renal replacement therapy but a substantial increase in the lengths of stay in the intensive care unit and hospital. Our results may help bedside decision-making regarding ECMO initiation in patients with severe respiratory distress syndrome.
- Oferta de oxigênio, remoção de dióxido de carbono, transferência de energia aos pulmões e comportamento da hipertensão pulmonar durante o suporte com oxigenação por membrana extracorpórea: um modelo matemático(2019) BESEN, Bruno Adler Maccagnan Pinheiro; ROMANO, Thiago Gomes; ZIGAIB, Rogerio; MENDES, Pedro Vitale; MELRO, Lívia Maria Garcia; PARK, MarceloABSTRACT Objective: To describe (1) the energy transfer from the ventilator to the lungs, (2) the match between venous-venous extracorporeal membrane oxygenation (ECMO) oxygen transfer and patient oxygen consumption (VO2), (3) carbon dioxide removal with ECMO, and (4) the potential effect of systemic venous oxygenation on pulmonary artery pressure. Methods: Mathematical modeling approach with hypothetical scenarios using computer simulation. Results: The transition from protective ventilation to ultraprotective ventilation in a patient with severe acute respiratory distress syndrome and a static respiratory compliance of 20mL/cm H2O reduced the energy transfer from the ventilator to the lungs from 35.3 to 2.6 joules/minute. A hypothetical patient, hyperdynamic and slightly anemic with VO2 = 200mL/minute, can reach an arterial oxygen saturation of 80%, while maintaining the match between the oxygen transfer by ECMO and the VO2 of the patient. Carbon dioxide is easily removed, and normal PaCO2 is easily reached. Venous blood oxygenation through the ECMO circuit may drive the PO2 stimulus of pulmonary hypoxic vasoconstriction to normal values. Conclusion: Ultraprotective ventilation largely reduces the energy transfer from the ventilator to the lungs. Severe hypoxemia on venous-venous-ECMO support may occur despite the matching between the oxygen transfer by ECMO and the VO2 of the patient. The normal range of PaCO2 is easy to reach. Venous-venous-ECMO support potentially relieves hypoxic pulmonary vasoconstriction.
- Update on the Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guideline of the Brazilian Society of Cardiology-2019(2019) BERNOCHE, Claudia; TIMERMAN, Sergio; POLASTRI, Thatiane Facholi; GIANNETTI, Natali Schiavo; SIQUEIRA, Adailson Wagner da Silva; PISCOPO, Agnaldo; SOEIRO, Alexandre de Matos; REIS, Amelia Gorete Afonso da Costa; TANAKA, Ana Cristina Sayuri; THOMAZ, Ana Maria; QUILICI, Ana Paula; CATARINO, Andrei Hilario; RIBEIRO, Anna Christina de Lima; BARRETO, Antonio Carlos Pereira; AZEVEDO FILHO, Antonio Fernando Barros de; PAZIN FILHO, Antonio; TIMERMAN, Ari; SCARPA, Bruna Romanelli; TIMERMAN, Bruno; TAVARES, Caio de Assis Moura; MARTINS, Cantidio Soares Lemos; SERRANO JUNIOR, Carlos Vicente; MALAQUE, Ceila Maria Sant'Ana; PISANI, Cristiano Faria; BATISTA, Daniel Valente; LEANDRO, Daniela Luana Fernandes; SZPILMAN, David; GONCALVES, Diego Manoel; PAIVA, Edison Ferreira de; OSAWA, Eduardo Atsushi; LIMA, Eduardo Gomes; ADAM, Eduardo Leal; PEIXOTO, Elaine; EVARISTO, Eli Faria; AZEKA, Estela; SILVA, Fabio Bruno da; WEN, Fan Hui; FERREIRA, Fatima Gil; LIMA, Felipe Gallego; FERNANDES, Felipe Lourenco; GANEM, Fernando; GALAS, Filomena Regina Barbosa Gomes; TARASOUTCHI, Flavio; SOUZA, Germano Emilio Conceicao; FEITOSA FILHO, Gilson Soares; FORONDA, Gustavo; GUIMARAES, Helio Penna; ABUD, Isabela Cristina Kirnew; LEITE, Ivanhoe Stuart Lima; LINHARES FILHO, Jaime Paula Pessoa; MORAES JUNIOR, Joao Batista de Moura Xavier; FALCAO, Joao Luiz Alencar de Araripe; RAMIRES, Jose Antonio Franchini; CAVALINI, Jose Fernando; SARAIVA, Jose Francisco Kerr; ABRAO, Karen Cristine; PINTO, Lecio Figueira; BIANCHI, Leonardo Luis Torres; LOPES, Leonardo Nicolau Geisler Daud; PIEGAS, Leopoldo Soares; KOPEL, Liliane; GODOY, Lucas Colombo; TOBASE, Lucia; HAJJAR, Ludhmila Abrahao; DALLAN, Luis Augusto Palma; CANEO, Luiz Fernando; CARDOSO, Luiz Francisco; CANESIN, Manoel Fernandes; PARK, Marcelo; RABELO, Marcia Maria Noya; MALACHIAS, Marcus Vinicius Bolivar; GONCALVES, Maria Aparecida Batistao; ALMEIDA, Maria Fernanda Branco de; SOUZA, Maria Francilene Silva; FAVARATO, Maria Helena Sampaio; CARRION, Maria Julia Machline; GONZALEZ, Maria Margarita; BORTOLOTTO, Maria Rita de Figueiredo Lemos; MACATRAO-COSTA, Milena Frota; SHIMODA, Monica Satsuki; OLIVEIRA-JUNIOR, Mucio Tavares de; IKARI, Nana Miura; DUTRA, Oscar Pereira; BERWANGER, Otavio; PINHEIRO, Patricia Ana Paiva Correa; REIS, Patricia Feitosa Frota dos; CELLIA, Pedro Henrique Moraes; SANTOS FILHO, Raul Dias dos; GIANOTTO-OLIVEIRA, Renan; KALIL FILHO, Roberto; GUINSBURG, Ruth; MANAGINI, Sandrigo; LAGE, Silvia Helena Gelas; YEU, So Pei; FRANCHI, Sonia Meiken; SHIMODA-SAKANO, Tania; ACCORSI, Tarso Duenhas; LEAL, Tatiana de Carvalho Andreucci; GUIMARAES, Vanessa; SALLAI, Vanessa Santos; AVILA, Walkiria Samuel; SAKO, Yara Kimiko