LUCIANO CESAR PONTES DE AZEVEDO
Projetos de Pesquisa
Unidades Organizacionais
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
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- 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.
- 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.
- Challenges in patients supported with extracorporeal membrane oxygenation in Brazil(2012) MENDES, Pedro Vitale; MOURA, Ewandro; BARBOSA, Edzangela Vasconcelos Santos; HIROTA, Adriana Sayuri; SCORDAMAGLIO, Paulo Rogerio; AJJAR, Fabiana Maria; COSTA, Eduardo Leite Vieira; AZEVEDO, Luciano Cesar Pontes; PARK, Marcelo
- Severe hypoxemia during veno-venous extracorporeal membrane oxygenation: exploring the limits of extracorporeal respiratory support(2014) NUNES, Liane Brescovici; MENDES, Pedro Vitale; HIROTA, Adriana Sayuri; BARBOSA, Edzangela Vasconcelos; MACIEL, Alexandre Toledo; SCHETTINO, Guilherme Pinto Paula; COSTA, Eduardo Leite Vieira; AZEVEDO, Luciano Cesar Pontes; PARK, MarceloOBJECTIVE: Veno-venous extracorporeal oxygenation for respiratory support has emerged as a rescue alternative for patients with hypoxemia. However, in some patients with more severe lung injury, extracorporeal support fails to restore arterial oxygenation. Based on four clinical vignettes, the aims of this article were to describe the pathophysiology of this concerning problem and to discuss possibilities for hypoxemia resolution. METHODS: Considering the main reasons and rationale for hypoxemia during veno-venous extracorporeal membrane oxygenation, some possible bedside solutions must be considered: 1) optimization of extracorporeal membrane oxygenation blood flow; 2) identification of recirculation and cannula repositioning if necessary; 3) optimization of residual lung function and consideration of blood transfusion; 4) diagnosis of oxygenator dysfunction and consideration of its replacement; and finally 5) optimization of the ratio of extracorporeal membrane oxygenation blood flow to cardiac output, based on the reduction of cardiac output. CONCLUSION: Therefore, based on the pathophysiology of hypoxemia during veno-venous extracorporeal oxygenation support, we propose a stepwise approach to help guide specific interventions.
- Lung perfusion during veno-venous extracorporeal membrane oxygenation in a model of hypoxemic respiratory failure(2022) MENDES, Pedro Vitale; PARK, Marcelo; AZEVEDO, Luciano Cesar Pontes de; MORAIS, Caio Cesar Araujo; AMATO, Marcelo Brito Passos; COSTA, Eduardo Leite VieiraBackground: Veno-venous extracorporeal membrane oxygenation (ECMO) provides blood oxygenation and carbon dioxide removal in acute respiratory distress syndrome. However, during ECMO support, the native lungs still play an important role in gas exchange, functioning as a second oxygenator in series with ECMO. The hypoxic vasoconstriction mechanism diverts regional blood flow within the lungs away from regions with low oxygen levels, optimizing ventilation/perfusion matching. ECMO support has the potential to reduce this adaptive pulmonary response and worsen the ventilation/perfusion mismatch by raising venous oxygen partial pressure. Thus, the objective of this study was to evaluate the effect of ECMO on regional pulmonary perfusion and pulmonary hemodynamics during unilateral ventilation and posterior lung collapse. Methods: Five Agroceres pigs were instrumented, monitored and submitted to ECMO. We used the Electrical Impedance Tomography (EIT) to evaluate lung ventilation and perfusion in all protocol steps. Effects of ECMO support on pulmonary hemodynamics and perfusion involving two different scenarios of ventilation/perfusion mismatch: (1) right-lung selective intubation inducing collapse of the normal left lung and (2) dorsal lung collapse after repeated lung lavage. Data including hemodynamics, respiratory, lung perfusion/ventilation, and laboratory data over time were analyzed with a mixed generalized model using the subjects as a random factor. Results: The initiation of ECMO support provided a significant reduction in Mean Pulmonary Artery Pressure (PAPm) in both situations of ventilation/perfusion mismatch. However, distribution of lung perfusion did not change with the use of ECMO support. Conclusions: We found that the use of ECMO support with consequent increase in venous oxygen pressure induced a significant drop in PAPm with no detectable effect on regional lung perfusion in different scenarios of ventilation/perfusion mismatch.
- Burnout syndrome in intensive care physicians in time of the COVID-19: a cross-sectional study(2022) FUMIS, Renata Rego Lins; COSTA, Eduardo Leite Vieira; DAL'COL, Shoraya Virginio Carneiro; AZEVEDO, Luciano Cesar Pontes; PASTORE JUNIOR, LaerteObjectives To assess the prevalence of burnout syndrome among intensive care physicians working in a tertiary private hospital as well as their perceived impact of the COVID-19 pandemic on their life. Design A cross-sectional study. Setting Intensive care units dedicated to the care of COVID-19 in Hospital Sirio-Libanes, Sao Paulo, Southeastern part of Brazil. Participants Intensive care physicians. Interventions Each participant received an envelope with a questionnaire composed of demographic and occupational variables, information related to their personal and professional experiences facing the COVID-19 pandemic and the Maslach Burnout Inventory questionnaire. Primary and secondary outcomes measures The primary outcome was to assess the prevalence of burnout syndrome among physicians working in an intensive care unit dedicated to the care of COVID-19. Results A total of 51 from the universe of 63 (82%) intensive care physicians participated in the study. Nineteen (37.2%) met the criteria for burnout syndrome. In the three domains that characterise burnout syndrome, we found a low level of personal achievement in 96.1% of physicians interviewed, a high level of depersonalisation in 51.0% and 51.0% with a high level of emotional exhaustion. Decision-making conflicts between the intensive care unit team and other attending physicians were frequent (50% of all conflicts). A third of the participants had been diagnosed with COVID-19, 22 (43.1%) reported having a family member infected and 8 (15.7%) lost someone close to the COVID-19 pandemic. Participants felt that fear of infecting their loved ones was the aspect of their lives that changed most as compared with the prepandemic period. Conclusions Burnout syndrome was frequent among intensive care unit physicians treating patients with COVID-19 in a large tertiary private hospital. Future studies should expand our results to other private and public hospitals and test strategies to promote intensive care unit physicians' mental health.
- Transportation of patients on extracorporeal membrane oxygenation: a tertiary medical center experience and systematic review of the literature(2017) MENDES, Pedro Vitale; GALLO, Cesar de Albuquerque; BESEN, Bruno Adler Maccagnan Pinheiro; HIROTA, Adriana Sayuri; NARDI, Raquel de Oliveira; SANTOS, Edzangela Vasconcelos dos; LI, Ho Yeh; JOELSONS, Daniel; COSTA, Eduardo Leite Vieira; FORONDA, Flavia Krepel; AZEVEDO, Luciano Cesar Pontes; PARK, MarceloBackground: Utilization of extracorporeal membrane oxygenation (ECMO) has increased worldwide, but its use remains restricted to severely ill patients, and few referral centers are properly structured to offer this support. Inter-hospital transfer of patients on ECMO support can be life-threatening. In this study, we report a single-center experience and a systematic review of the available published data on complications and mortality associated with ECMO transportation. Methods: We reported single-center data regarding complications and mortality associated with the transportation of patients on ECMO support. Additionally, we searched multiple databases for case series, observational studies, and randomized controlled trials regarding mortality of patients transferred on ECMO support. Results were analyzed independently for pediatric (under 12 years old) and adult populations. We pooled mortality rates using a random-effects model. Complications and transportation data were also described. Results: A total of 38 manuscripts, including our series, were included in the final analysis, totaling 1481 patients transported on ECMO support. A total of 951 patients survived to hospital discharge. The pooled survival rates for adult and pediatric patients were 62% (95% CI 57-68) and 68% (95% CI 60-75), respectively. Two deaths occurred during patient transportation. No other complication resulting in adverse outcome was reported. Conclusion: Using the available pooled data, we found that patient transfer to a referral institution while on ECMO support seems to be safe and adds no significant risk of mortality to ECMO patients.
- Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: A cohort study(2020) SOCOLOVITHC, Rachel Lane; FUMIS, Renata Rego Lins; TOMAZINI, Bruno Martins; PASTORE, Laerte; GALAS, Filomena Regina Barbosa Gomes; AZEVEDO, Luciano Cesar Pontes de; COSTA, Eduardo Leite VieiraBackground The coronavirus disease (COVID-19) pandemic has brought significant challenges worldwide, with high mortality, increased use of hospital resources, and the collapse of healthcare systems. We aimed to describe the clinical outcomes of critically ill COVID-19 patients and assess the impact on the use of hospital resources and compare with critically ill medical patients without COVID-19. Methods and findings In this retrospective cohort study, we included patients diagnosed with COVID-19 admitted to a private ICU in Sao Paulo, Brazil from March to June 2020. We compared these patients with those admitted to the unit in the same period of the previous year. A total of 212 consecutive patients with a confirmed diagnosis of COVID-19 were compared with 185 medical patients from the previous year. Patients with COVID-19 were more frequently males (76% vs. 56%, p<0.001) and morbidly obese (7.5% vs. 2.2%, p = 0.027), and had lower SAPS 3 (49.65 (12.19) vs. 55.63 (11.94), p<0.001) and SOFA scores (3.78 (3.53) vs. 4.48 (3.11), p = 0.039). COVID-19 patients had a longer ICU stay (median of 7 vs. 3 days, p<0.001), longer duration of mechanical ventilation (median of 9 vs. 4 days, p = 0.003), and more frequent tracheostomies (10.8 vs. 1.1%, p<0.001). Survival rates until 28 days were not statistically different (91% vs. 85.4%, p = 0.111). After multivariable adjustment for age, gender, SAPS 3, and Charlson Comorbidity Index, COVID-19 remained not associated with survival at 28 days (HR 0.59, 95% CI 0.33-1.06, p = 0.076). Among patients who underwent invasive mechanical ventilation, the observed mortality at 28-days was 16.2% in COVID-19 patients compared to 34.6% in the previous year. Conclusions COVID-19 required more hospital resources, including invasive and non-invasive ventilation, had a longer duration of mechanical ventilation, and a more prolonged ICU and hospital length of stay. There was no difference in all-cause mortality at 28 and 60 days, suggesting that health systems preparedness be an important determinant of clinical outcomes.
bookPart Suporte extracorpóreo cardiovascular e respiratório(2020) PARK, Marcelo; AZEVEDO, Luciano César Pontes de; COSTA, Eduardo Leite Vieira- Effect of continuous dialysis on blood pH in acidemic hypercapnic animals with severe acute kidney injury: a randomized experimental study comparing high vs. low bicarbonate affluent(2017) ROMANO, Thiago Gomes; AZEVEDO, Luciano Cesar Pontes; MENDES, Pedro Vitale; COSTA, Eduardo Leite Vieira; PARK, MarceloBackground: Controlling blood pH during acute ventilatory failure and hypercapnia in individuals suffering from severe acute kidney injury (AKI) and undergoing continuous renal replacement therapy (CRRT) is of paramount importance in critical care settings. In this situation, the optimal concentration of sodium bicarbonate in the dialysate is still an unsolved question in critical care since high concentrations may worsen carbon dioxide levels and low concentrations may not be as effective in controlling pH. Methods: We performed a randomized, non-blinded, experimental study. AKI was induced in 12 female pigs via renal hilum ligation and hypoventilation by reducing the tidal volume during mechanical ventilation with the goal of achieving a pH between 7.10-7.15. After achieving the target pH, animals were randomized to undergo isovolemic hemodialysis with one of two bicarbonate concentrations in the dialysate (40 mEq/L [group 40] vs. 20 mEq/L [group 20]). Results: Hemodynamic, respiratory, and laboratory data were collected. The median pH value at CRRT initiation was 7.14 [7.12, 7.15] in group 20 and 7.13 [7.09, 7.14] in group 40 (P = ns). The median baseline PaCO2 was 74 [72, 81] mmHg in group 20 vs. 79 [63, 85] mmHg in group 40 (P = ns). After 3 h of CRRT, the pH value was 7.05 [6.95, 7.09] in group 20 and 7.12 [7.1, 7.14] in group 40 (P < 0.05), with corresponding values of PaCO2 of 85 [79, 88] mmHg vs. 81 [63, 100] mmHg (P = ns). The difference in pH after 3 h was due to a metabolic component [standard base excess -10.4 [-12.5, -9.5] mEq/L in group 20 vs. -7.6 [-9.2, -5.1] mEq/L in group 40) (P < 0.05)]. Despite the increased infusion of bicarbonate in group 40, the blood CO2 content did not change during the experiment. The 12-h survival rate was higher in group 40 (67% vs. 0, P = 0.032). Conclusions: A higher bicarbonate concentration in the dialysate of animals undergoing hypercapnic respiratory failure was associated with improved blood pH control without increasing the PaCO2 levels.