MARIA JOSE CARVALHO CARMONA
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Cirurgia, Faculdade de Medicina - Docente
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
Instituto Central, 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 - Médico
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/08 - Laboratório de Anestesiologia, Hospital das Clínicas, Faculdade de Medicina
10 resultados
Resultados de Busca
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- 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.
- Influence of cardiopulmonary bypass on cefuroxime plasma concentration and pharmacokinetics in patients undergoing coronary surgery(2012) FERREIRA, Fabiana; SANTOS, Silvia; NASCIMENTO, Jorge; STRABELLI, Tania; CARMONA, MariaThe aims of this study were to evaluate the influence of cardiopulmonary bypass (CPB) on the plasma concentrations and pharmacokinetics of cefuroxime and to assess whether the cefuroxime dose regimen (a 1.5 g dose, followed by 750 mg every 6 h for 24 h) is adequate for cardiac surgery antibiotic prophylaxis. A prospective, controlled, observational study compared patients undergoing coronary surgery with CPB (CPB group, n = 10) or off-pump surgery (off-pump group, n = 9). After each cefuroxime dose, blood samples were sequentially collected and analysed using high-efficiency chromatography. For demographic data and pharmacokinetic parameters, the authors used Fisher's exact test for nominal variables and Student's t-test and the Mann-Whitney U-test for parametric and non-parametric variables, respectively. Plasma concentrations were compared using ANOVA, and the percentage of patients with a remaining plasma concentration of > 16 mg/l within 6 h after each bolus was quantified in tabular form. After each cefuroxime bolus was administered, both groups presented a significant decrease in plasma concentration over time (P < 0.001), without differences between the groups. The mean CPB time of 59.7 +/- 21.1 min did not change cefuroxime plasma concentrations or pharmacokinetics. The mean clearance +/- SD (ml/kg/min) and median elimination half-life (h) of the CPB group versus the off-pump group were 1.7 +/- 0.7 versus 1.6 +/- 0.6 (P = 0.67), respectively, and 2.2 versus 2.3 (P = 0.49), respectively. Up to 3 h following the first bolus of 1.5 g, but not after 6 h, all patients had plasma concentrations > 16 mg/l (CPB group = 20% and off-pump group = 44%). However, after all 750 mg boluses were administered, concentrations < 16 mg/dl were reached within 3 h. CPB does not influence cefuroxime plasma concentrations. The dosing regimen is adequate for the intraoperative period, but in the immediate postoperative period, it requires further review.
- S100B protein and neuron-specific enolase as predictors of cognitive dysfunction after coronary artery bypass graft surgery A prospective observational study(2016) SILVA, Fernando P.; SCHMIDT, Andre P.; VALENTIN, Livia S.; PINTO, Katia O.; ZEFERINO, Suely P.; OSES, Jean P.; WIENER, Carolina D.; OTSUKI, Denise A.; TORT, Adriano B. L.; PORTELA, Luis V.; SOUZA, Diogo O.; AULER JR., Jose O. C.; CARMONA, Maria J. C.BACKGROUND Postoperative cognitive dysfunction (POCD) may be related to the systemic inflammatory response and an increase in serum markers of brain injury such as S100B protein and neuron-specific enolase (NSE). OBJECTIVE The study aims to evaluate the association between POCD and serum levels of S100B and NSE after coronary artery bypass grafting surgery (CABG). DESIGN Prospective observational study. SETTING Single university teaching hospital. PATIENTS We investigated 88 patients undergoing CABG. MAIN OUTCOMES MEASURES Cognitive function was measured preoperatively, and at the 21st and 180th postoperative days (i.e. 6 months after surgery). S100B protein and NSE serum levels were evaluated preoperatively, after induction of anaesthesia, at the end of surgery and at 6 and 24 h after surgery. RESULTS The incidence of POCD was 26.1% at 21 days after surgery and 22.7% at 6 months after surgery. Increased serum levels of S100B protein and NSE were observed postoperatively and may indicate brain damage. CONCLUSION Although serum levels of S100B protein and NSE are both significantly increased postoperatively, our findings indicate that serum levels of S100B protein may be more accurate than NSE in the detection of POCD after CABG.
- Application of a pharmacokinetics-pharmacodynamics approach to the free propofol plasma levels during coronary artery bypass grafting surgery with hypothermic cardiopulmonary bypass(2018) SILVA-FILHO, Carlos R.; BARBOSA, Ricardo Antonio G.; SILVA- JR., Carlindo V.; MALBOUISSON, Luiz M. S.; CARMONA, Maria Jose C.; JORGE-SANTOS, Silvia Regina C.OBJECTIVES: The objective of this study was to apply a pharmacokinetics-pharmacodynamics approach to investigate the free propofol plasma levels in patients undergoing coronary artery bypass grafting under hypothermic conditions compared with the off-pump procedure. METHODS: Nineteen patients scheduled for on-pump coronary artery bypass grafting under hypothermic conditions (n=10) or the equivalent off-pump surgery (n=9) were anesthetized with sufentanil and propofol target-controlled infusion (2 mg/mL) during surgery. The propofol concentration was then reduced to 1 mu g/mL, and a pharmacokinetics-pharmacodynamics analysis using the maximum-effect-sigmoid model obtained by plotting the bispectral index values against the free propofol plasma levels was performed. RESULTS: Significant increases (two-to five-fold) in the free propofol plasma levels were observed in the patients subjected to coronary artery bypass grafting under hypothermic conditions. The pharmacokinetics of propofol varied according to the free drug levels in the hypothermic on-pump group versus the off-pump group. After hypothermic coronary artery bypass was initiated, the distribution volume increased, and the distribution half-life was prolonged. Propofol target-controlled infusion was discontinued when orotracheal extubation was indicated, and the time to patient extubation was significantly higher in the hypothermic on-pump group than in the off-pump group (459 versus 273 min, p=0.0048). CONCLUSIONS: The orotracheal intubation time was significantly longer in the hypothermic on-pump group than in the off-pump group. Additionally, residual hypnosis was identified through the pharmacokinetics-pharmacodynamics approach based on decreases in drug plasma protein binding in the hypothermic on-pump group, which could explain the increased hypnosis observed with this drug in this group of patients.
article 3 Citação(ões) na Scopus Evaluation of Cytokine Levels and Pulmonary Function in Patients Undergoing Coronary Artery Bypass Graft(2011) MACHADO, Luciano Brandao; NEGRI, Elnara Marcia; BONAFE, Wanderley Wesley; SANTOS, Luciana Moraes; MALBOUISSON, Luis Marcelo Sa; CARMONA, Maria Jose CarvalhoThe Summary: Machado LB, Negri EM, Bonafe WW, Santos LM, Malbouisson LMS, Carmona MJC - Evaluation of Cytokine Levels and Pulmonary Function in Patients Undergoing Coronary Artery Bypass Grafts. Background and objectives: Systemic inflammatory response syndrome is commonly observed in coronary artery bypass grafts (CABG) with cardiopulmonary bypass (CB). The objective of this study was to evaluate the systemic and pulmonary levels of cytokines and their correlation with lung function in patients undergoing myocardial revascularization (MR) with CB. Methods: This study was approved by the Institutional Ethics Committee, and 13 patients undergoing MR with CB were evaluated. After anesthetic induction and at the end of CB, plasma and bronchoalveolar lavage levels of IL-1 beta, IL-6, IL-8, IL-10, and TNF-alpha were determined. The duration of CB and surgery, PaO(2)/FiO(2) ratio, alveolar-arterial oxygen gradient (A-a gradient), shunt, and lung compliance were evaluated. Results were submitted to analysis of variance for repeated measurements ((star)p < 0.05) and Spearman's correlation coefficient. Results: We observed increased levels of cytokines in plasma and bronchoalveolar lavage after CB and a direct relationship between the increase in IL-beta and decrease in lung compliance (p = 0.0439), as well as the inverse relationship between the increase in IL-10 and a decrease in compliance (p = 0.0325). The increase in IL-6 was directly related to the duration of CB (p = 0.012), while the increase in IL-8 was directly related to the duration of surgery (p < 0.0001). Levels of interleukin-1 beta, IL-8, and TNF-alpha in bronchoalveolar lavage were higher than in plasma. Conclusions: There is an increase in cytokine levels in plasma and bronchoalveolar lavage after CB, as well as a correlation between increased cytokine levels and CB duration and surgery and changes in lung compliance.- S100B protein and neuron-specific enolase as predictors of postoperative cognitive dysfunction in aged dogs: a case-control study(2020) ZBORIL, Sabrina; SCHMIDT, Andre P.; OSES, Jean P.; WIENER, Carolina D.; V, Luis Portela; SOUZA, Diogo O.; AULER JUNIOR, Jose O. C.; CARMONA, Maria J. C.; FUGITA, Mariana S.; FLOR, Patricia B.; CORTOPASSI, Silvia R. G.Objective Postoperative cognitive dysfunction (POCD) may be related to brain injury. S100B protein and neuronspecific enolase (NSE) have been investigated as potential biochemical markers of neural cell injury in animals and humans. This study aimed to investigate the association between POCD, brain injury and serum concentrations of S100B and NSE after periodontal surgery in aged dogs. Study design Prospective observational animal study. Animals A total of 24 male and female dogs undergoing periodontal surgery. Methods Dogs were separated into two groups based on age: control group, 10 dogs <= 8 years and aged group, 14 dogs > 8 years. Cognitive function was measured preoperatively and on the seventh postoperative day using the Canine Cognitive Dysfunction Rating scale and the Age-Related Cognitive and Affective Disorders scale. S100B protein and NSE serum concentrations were measured before and immediately after the surgery. Results POCD was not observed after surgery in the present study. Serum concentrations of S100B and NSE were increased postoperatively in the control group but not in the aged group (p = 0.04 and 0.03, respectively). Preoperative S100B serum concentrations were significantly higher in the aged group (p = 0.01). Conclusions There was no association between POCD and high concentrations of S100B and NSE in dogs. However, increased postoperative serum concentrations of S100B and NSE were found in the control group after surgery, an effect that may indicate neural damage.
- Goal-directed therapy in patients with early acute kidney injury: a multicenter randomized controlled trial(2018) AMENDOLA, Cristina Prata; SILVA-JR, Joao Manoel; CARVALHO, Taisa; SANCHES, Luciana Coelho; SILVA, Ulysses Vasconcelos de Andrade e; ALMEIDA, Rosana; BURDMANN, Emmanuel; LIMA, Emerson; BARBOSA, Fabiana Ferreira; FERREIRA, Renata Souza; CARMONA, Maria Jose C.; MALBOUISSON, Luiz Marcelo Sa; NOGUEIRA, Fernando A. M.; AULER-JUNIOR, Jose Otavio Costa; LOBO, Suzana MargarethOBJECTIVES: Acute kidney injury is associated with many conditions, and no interventions to improve the outcomes of established acute kidney injury have been developed. We performed this study to determine whether goaldirected therapy conducted during the early stages of acute kidney injury could change the course of the disease. METHODS: This was a multicenter prospective randomized controlled study. Patients with early acute kidney injury in the critical care unit were randomly allocated to a standard care (control) group or a goal-directed therapy group with 8h of intensive treatment to maximize oxygen delivery, and all patients were evaluated during a period of 72h. ClinicalTrials.gov: NCT02414906. RESULTS: A total of 143 patients were eligible for the study, and 99 patients were randomized. Central venous oxygen saturation was significantly increased and the serum lactate level significantly was decreased from baseline levels in the goal-directed therapy group (p.0.001) compared to the control group (p.O.572). No significant differences in the change in serum creatinine level (p.0.96), persistence of acute kidney injury beyond 72h (p.0.064) or the need for renal replacement therapy (p.0.82) were observed between the two groups. In-hospital mortality was significantly lower in the goal-directed therapy group than in the control group (33% vs. 51%; RR: 0.61, 95% CI: 0.37-1.00, p=0.048, number needed to treat=5). CONCLUSIONS: Goal-directed therapy for patients in the early stages of acute kidney injury did not change the disease course.
- Leukocyte Depletion During CPB: Effects on Inflammation and Lung Function(2014) AMORIM, Celio Gomes de; MALBOUISSON, Luiz Marcelo Sa; SILVA JR., Francisco Costa da; FIORELLI, Alfredo Inacio; MURAKAMI, Caroline Kameio Fernandes; CARMONA, Maria Jose CarvalhoCardiopulmonary bypass (CPB) is related to inflammatory response and pulmonary dysfunction. The aim of this study was to evaluate the effects of CPB leukocyte filtration on inflammation and lung function after coronary artery bypass grafting (CABG). A prospective randomized study was performed to compare CABG patients undergoing CPB leukocyte filtration (n = 9) or standard CPB (n = 11). Computed tomography, oxygenation, leukocyte count, hemodynamic data, PaO2/FiO(2), shunt fraction, interleukins, elastase, and myeloperoxidase were evaluated. Data were analyzed using two-factor ANOVA for repeated measurements. The filtered group showed lower neutrophil counts up to 50 min of CPB, lower shunt fraction up to 6 h after surgery, and lower levels of IL-10 at the end of surgery (p < 0.05). There was no statistically significant difference between groups related to other parameters. Leukodepletion during CPB results in neutrophil sequestration by a short time, decreased IL-10 serum levels, and lower worsening of lung function only temporarily.
- Impact of perioperative hemodynamic optimization therapies in surgical patients: economic study and meta-analysis(2020) SILVA-JR, Joao M.; MENEZES, Pedro Ferro L.; LOBO, Suzana M.; CARVALHO, Flavia Helena S. de; OLIVEIRA, Mariana Augusta N. de; CARDOSO FILHO, Francisco Nilson F.; FERNANDO, Bruna N.; CARMONA, Maria Jose C.; TEICH, Vanessa D.; MALBOUISSON, Luiz Marcelo S.Background Several studies suggest that hemodynamic optimization therapies can reduce complications, the length of hospital stay and costs. However, Brazilian data are scarce. Therefore, the objective of this analysis was to evaluate whether the improvement demonstrated by hemodynamic optimization therapy in surgical patients could result in lower costs from the perspective of the Brazilian public unified health system. Methods A meta-analysis was performed comparing surgical patients who underwent hemodynamic optimization therapy (intervention) with patients who underwent standard therapy (control) in terms of complications and hospital costs. The cost-effectiveness analysis evaluated the clinical and financial benefits of hemodynamic optimization protocols for surgical patients. The analysis considered the clinical outcomes of randomized studies published in the last 20 years that involved surgeries and hemodynamic optimization therapy. Indirect costs (equipment depreciation, estate and management activities) were not included in the analysis. Results A total of 21 clinical trials with a total of 4872 surgical patients were selected. Comparison of the intervention and control groups showed lower rates of infectious (RR = 0.66; 95% CI = 0.58-0.74), renal (RR = 0.68; 95% CI = 0.54-0.87), and cardiovascular (RR = 0.87; 95% CI = 0.76-0.99) complications and a nonstatistically significant lower rate of respiratory complications (RR = 0.82; 95% CI = 0.67-1.02). There was no difference in mortality (RR = 1.02; 95% CI = 0.80-1.3) between groups. In the analysis of total costs, the intervention group showed a cost reduction of R$396,024.83-BRL ($90,161.38-USD) for every 1000 patients treated compared to the control group. The patients in the intervention group showed greater effectiveness, with 1.0 fewer days in the intensive care unit and hospital. In addition, there were 333 fewer patients with complications, with a consequent reduction of R$1,630,341.47-BRL ($371,173.27-USD) for every 1000 patients treated. Conclusions Hemodynamic optimization therapy is cost-effective and would increase the efficiency of and decrease the burden of the Brazilian public health system.
article 1 Citação(ões) na Scopus PK/PD of Morphine for Postoperative Analgesia after Coronary Artery Bypass Grafting. Intrathecal Morphine Significantly Reduces Drug Consumption(2012) SANTOS, Veronica C. J.; SANCHES-GIRAUD, Cristina; LANCHOTE, Vera L.; SANTOS, Luciana M.; CARMONA, Maria J. C.; SANTOS, Silvia R. C. J.The aim of the present study was to evaluate intrathecal morphine outcome on postoperative pain and apply pharmacokinetic/pharmacodynamic model to justify morphine consumption, plasma concentration and pain intensity during coronary artery bypass grafting surgery. Thirty six patients were prospectively randomized for general anesthesia and allocated in the control or morphine (400 mu g intrathecal) group. At postoperative period, all patients received a loading dose of morphine (1 mg bolus), and then patient-controlled analgesia device was installed and delivered until 36 h. Blood samples was collected from venous catheter, morphine plasma concentrations were determined by liquid chromatography and pain intensity evaluated by visual analogue scale. Drug dose requirements and pain intensity at rest were different between groups. No kinetic parameters difference was obtained. Maximum effect model and hysteresis curve were proposed to correlate drug plasma concentration versus time, drug consumption and pain intensity. Intrathecal morphine reduces at rest morphine consumption and pain intensity postoperatively; the best fit pharmacokinetic/pharmacodynamic models were maximum effect and hysteresis curve.