LUDHMILA ABRAHAO HAJJAR

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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

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  • article 34 Citação(ões) na Scopus
    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-Louis
    Background: 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.
  • article 0 Citação(ões) na Scopus
    Blood Transfusion and Cardiac Surgery Reply
    (2011) HAJJAR, Ludhmila A.; GALAS, Filomena R. B. G.; VINCENT, Jean-Louis
  • article 19 Citação(ões) na Scopus
    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 Abrahao
    Objectives: 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.
  • article 56 Citação(ões) na Scopus
    Blood transfusion in cardiac surgery is a risk factor for increased hospital length of stay in adult patients
    (2013) GALAS, Filomena R. B. G.; ALMEIDA, Juliano P.; FUKUSHIMA, Julia T.; OSAWA, Eduardo A.; NAKAMURA, Rosana E.; SILVA, Carolina M. P. D. C.; ALMEIDA, Elisangela Pinto Marinho de; AULER JR., Jose Otavio Costa; VINCENT, Jean-Louis; HAJJAR, Ludhmila A.
    Background: Allogeneic red blood cell (RBC) transfusion has been proposed as a negative indicator of quality in cardiac surgery. Hospital length of stay (LOS) may be a surrogate of poor outcome in transfused patients. Methods: Data from 502 patients included in Transfusion Requirements After Cardiac Surgery (TRACS) study were analyzed to assess the relationship between RBC transfusion and hospital LOS in patients undergoing cardiac surgery and enrolled in the TRACS study. Results: According to the status of RBC transfusion, patients were categorized into the following three groups: 1) 199 patients (40%) who did not receive RBC, 2) 241 patients (48%) who received 3 RBC units or fewer (low transfusion requirement group), and 3) 62 patients (12%) who received more than 3 RBC units (high transfusion requirement group). In a multivariable Cox proportional hazards model, the following factors were predictive of a prolonged hospital length of stay: age higher than 65 years, EuroSCORE, valvular surgery, combined procedure, LVEF lower than 40% and RBC transfusion of >3 units. Conclusion: RBC transfusion is an independent risk factor for increased LOS in patients undergoing cardiac surgery. This finding highlights the adequacy of a restrictive transfusion therapy in patients undergoing cardiac surgery.
  • article 0 Citação(ões) na Scopus
    Liberal Transfusion Practice or Perioperative Treatment of Anemia to Avoid Transfusion? Reply
    (2015) VINCENT, Jean-Louis; HAJJAR, Ludhmila A.; ALMEIDA, Juliano Pinheiro de
  • article 63 Citação(ões) na Scopus
    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-Louis
    While 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.
  • article 21 Citação(ões) na Scopus
    Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial
    (2019) GARG, Amit X.; CHAN, Matthew T. V.; CUERDEN, Meaghan S.; DEVEREAUX, P. J.; ABBASI, Seyed Hesameddin; HILDEBRAND, Ainslie; LAMONTAGNE, Francois; LAMY, Andre; NOISEUX, Nicolas; PARIKH, Chirag R.; PERKOVIC, Vlado; QUANTZ, Mackenzie; ROCHON, Antoine; ROYSE, Alistair; SESSLER, Daniel I.; SHAH, Pallav J.; SONTROP, Jessica M.; TAGARAKIS, Georgios I.; TEOH, Kevin H.; VINCENT, Jessica; WALSH, Michael; YARED, Jean-Pierre; YUSUF, Salim; WHITLOCK, Richard P.; WHITLOCK, R.; SEMELHAGO, L.; CHU, V.; DYUB, A.; CYBULSKY, I.; OOSTEEN, R. Van; CORDOVA, G.; QUANTZ, M. A.; MCKENZIE, F. N.; FOX, S.; CHASE, L.; STEVENS, L. M.; PRIETO, I.; BASILE, F.; FINEGAN, B. A.; BRYDEN, C.; MEYER, S.; CHAPPELL, A.; MAZER, C. D.; DIXON, J.; YAGNIK, S.; CRESCINI, C.; VERMA, S.; LEGARE, J. F.; GREENTREE, D.; COUTU, M.; TEIJEIRA, J.; WILEY, W.; PENISTON, C.; TENG, C.; ROCHON, A. G.; LAMARCHE, Y.; DESCHAMPS, A.; VOISINE, P.; DAGENAIS, F.; SINGAL, R. K.; BROWN, C. D.; KIESER, T. M.; ROBINSON, R.; FREMES, S. E.; CHRISTAKIS, G. T.; MELVIN, K. N.; PARSONS, M.; ZHENG, H.; YU, J.; XU, W.; ZHANG, Q.; CHEN, C.; YU, H.; ZENG, J.; ZUO, Y.; LIU, J.; ZHANG, T.; SUN, Y.; SONG, D.; DONG, H.; CHEN, M.; ZHAO, J.; TAO, L.; HUANG, W.; CHENG, Y.; LONG, Y. S.; LEI, W.; ZHANG, W.; XU, M. Y.; QING, E.; XIAO, Y. B.; KARUNAKARAN, J.; PILLAI, V. V.; REDDY, P. B.; KUNDAN, S.; JAIN, A. R.; MALLYA, S. S.; MEHTA, C. B.; SHUKLA, V.; KURUVILA, K.; KARTHIKEYAN, G.; DEVAGOUROU, V.; HOTE, M. P.; AIRAN, B.; PADMANABHAN, C.; SRINIVASAN, M.; AGARWAL, S. K.; PANDE, S.; RAO, P. Simha Mohan; MATH, R.; SHANKAR, B. P. R.; VAIJYANATH, P. H.; NAIR, S. K.; AYAPATI, D. R.; KURZ, A.; AWAIS, A.; PANJASAWATWONG, K.; KASHY, B. K.; HUFFMYER, J. L.; SCALZO, D. C.; KAZEMI, A.; HUANG, K. F.; PARVATHANENI, S. V.; GARDNER, J. C.; MALIK, M. R.; ESHRAGHI, Y.; KRAMER, R. S.; ESSANDOH, M. K.; PORTILLO, J.; AYAD, S. S.; AKHTAR, Z.; CASTRESANA, M. R.; COLLARD, C. D.; RODRIGUEZ-BLANCO, Y. F.; EATON, M. P.; VILLAR, J. C.; UMANA, J. P.; DOMINGUEZ, C. L.; ALVARADO, P. A.; ZULUAGA, D.; ABELLO, M.; SARQUIS, T.; VAQUIRO, E.; OLIVEROS, C. A.; MANRIQUE, E. J.; VASQUEZ, S.; ORTIZ, L. M.; HOLLIDAY, J.; GRIFFIN, R.; ROYSE, A. G.; ROYSE, C. F.; WILLIAMS, Z.; PAPARELLA, D.; ROTUNNO, C.; PALO, M. De; MARGARI, V.; ALFIERI, O.; FERRARA, D.; SCHIAVI, D.; PAROLARI, A.; MYASOEDOVA, V. A.; DAPRATI, A.; FEO, M. De; BANCONE, C.; BARTOLOMEO, R. Di; PACINI, D.; RIBEZZO, M.; KARIMI, A.; SALEHIOMRAN, A.; HAJIGHASEMI, A.; BINA, P.; STRAKA, Z.; HLAVICKA, J.; LUKAC, P.; VIK, K.; MOSNA, F.; TSILIMINGAS, N. B.; SIMOPOULOS, V. N.; TSOLAKI, F.; RIVILLA, M. T.; GALAN, J.; NUNEZ, J. A. F.; GONZALEZ, A.; RUIZ, D.; RODRIGUEZ, M. Orts; ISSA, M.; NOVA, D. C. Vila; MAIA, L. N.; NAKAZONE, M. A.; CIVIDANES, G. V. Lico e; HAJJAR, L. A.; NETO, V. Avila; LUCCHESE, F. A.; STOLF, N. A.; HUTSCHALA, D.; RUETZLER, K.; SIMA, B.; ENGELEN, S.; BORMS, S.; VELDE, M. Van de; REX, S.; HERT, S. G. De; HO, A. M. H.; CHAN, M. T. V.; UNDERWOOD, M. J.; BISURGI, D. Deluca; TORRES, D.; BUGGY, D. J.
    BACKGROUND: Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS: We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (>= 26.5 mu mol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS: Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION: Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery.
  • conferenceObject
    VASOPRESSIN OR NOREPINEPHRINE IN VASOPLEGIC AFTER CARDIAC SURGERY (YANCS STUDY): A RANDOMIZED, DOUBLE-BLIND AND CONTROLLED STUDY
    (2014) HAJJAR, L. A.; VINCENT, J. L.; RHODES, A.; GALAS, F.; FUKUSHIMA, J. T.; OSAWA, E. A.; GRANDE, S. M.; ALMEIDA, J. P.; ZEFFERINO, S.; CAMARA, L.; JATENE, F. B.; FILHO, R. K.
  • article 13 Citação(ões) na Scopus
    Is there still a place for the Swan-Ganz catheter? We are not sure
    (2018) BACKER, Daniel De; HAJJAR, Ludhmila A.; PINSKY, Michael R.
  • article 57 Citação(ões) na Scopus
    How can assessing hemodynamics help to assess volume status?
    (2022) BACKER, Daniel De; AISSAOUI, Nadia; CECCONI, Maurizio; CHEW, Michelle S.; DENAULT, Andre; HAJJAR, Ludhmila; HERNANDEZ, Glenn; MESSINA, Antonio; MYATRA, Sheila Nainan; OSTERMANN, Marlies; PINSKY, Michael R.; TEBOUL, Jean-Louis; VIGNON, Philippe; VINCENT, Jean-Louis; MONNET, Xavier
    In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy.