Higiene no Bloco...

A propósito de lavagem das mãos no Bloco...

Liver explosion!

Featured images from Trauma.org (>>>>vide links>>>>)

"Luis Filipe Pinheiro Hospital S. Teotónio - VISEU PORTUGAL

This patient has sustained a gunshot wound in the LUQ. Transfered imediately to the OR, a xiphopuibic laparotomy with extention to the RUQ was done. He had a blasted liver (Grade V lesion) as the only intrabdominal lesion. No other visceral injuries! The patient died on table from exanguination."

Bicarbonato de sódio...

A propósito de uma conversa que tive com a Jacinta na nossa última urgência sobre a administração de bicarbonato de sódio a doentes com acidose láctica, fica o resumo de um artigo de revisão sobre o assunto.

O artigo apresenta e analisa criticamente resultados de vários estudos experimentais e clínicos e está dividido nas seguintes áreas:

• Is a low pH bad?
• Can sodium bicarbonate raise the pH in vivo?
• Does increasing the blood pH with sodium bicarbonate have any salutary effects?
• Does sodium bicarbonate have negative side effects?

Sodium bicarbonate is clearly effective in raising the arterial pH in critically ill patients with lactic acidosis. The impact on intracellular pH is unknown in such patients, but extrapolation from extensive animal studies suggests that it is negative.

Despite the correction of arterial acidemia, sodium bicarbonate, like DCA, has no favorable cardiovascular effects, even for patients with severe acidemia and receiving continuous infusions of catecholamines. Although hemodynamic improvement is not the only mechanism by which bicarbonate might be beneficial, animal studies have failed to yield alternatives.

Even theoretical arguments in favor of sodium bicarbonate administration rely on a naive representation of acid-base physiology, ignoring the complex compartmentalization of pH, the second-level effects of bicarbonate infusion, the impact of carbon dioxide generation, or the negative consequences of hyperlactatemia.

We believe most clinicians who continue to use bicarbonate for patients with severe lactic acidosis do so largely because of their inclination to action: How can I “fail” to give bicarbonate when no alternative therapy is available and the mortality of this condition is so high? The oft-cited rationale for bicarbonate use, that it might ameliorate the hemodynamic depression of metabolic acidemia, has been disproved convincingly.

Any future role for bicarbonate in these patients depends on the formulation of new hypotheses of efficacy followed by animal and clinical studies to seek to confirm any proposed benefit. Given the current lack of evidence supporting its use, we cannot condone bicarbonate administration for patients with lactic acidosis. We extend this to those with pH , 7.2 on vasoactive drugs, inasmuch as bicarbonate has no measurable beneficial effects even in these sickest patients. Indeed, we do not give or advise bicarbonate infusion regardless of the pH.

Fonte: Forsythe SM, Schmidt GA: Sodium Bicarbonate for the Treatment of Lactic Acidosis. CHEST 2000; 117:260–267.

Manobra de Valsava

Em relação a uma discussão que foi levantada pela Teresa Leal sobre a manobra de Valsava (pergunta 61 da pág. 120 "The primary FRCA, A complete guide to preparation and passing"):


"Forced expiration against a closed glottis after a full inspiration.

Standardised form 40 mmHg held for 10 seconds

Previously used to expel pus from the middle ear.

[Antonio Valsava (1666-1723), Italian anatomist].





Phase I
Blood is expelled from the thoracic vessels by the increase in intrathoracic pressure.

Phase II
The increase in intrathoracic pressure causes a reduction of venous return, lowering the preload and BP

The baroreceptor reflex is activated, causing vasoconstriction and a tachycardia, raising BP towards normal.

Phase III
As intrathoracic pressure suddenly drops there is pooling of blood in the pulmonary vessels, causing a further drop in BP.

Phase IV
With venous return restored there is an overshoot, as compensatory mechanisms continue to operate.

The increased BP causes a baroreceptor mediated bradycardia.

The Valsalva manoeuvre is a useful bedside test of autonomic function. With autonomic dysfunction (e.g. autonomic neuropathy and drugs), the BP falls and remains low until the intrathoracic pressure is released. The changes in pulse rate and overshoot are absent. For reasons that are still obscure, patients with primary hyperaldosteronism also fail to show the heart rate changes and the blood pressure rise when the intrathoracic pressure returns to normal. Their response to the Valsalva manoeuvre returns to normal after removal of the aldosterone-secreting tumour.

Other abnormal responses

Square wave response
Seen in cardiac failure, constrictive pericarditis, cardiac tamponade and valvular heart disease. Blood pressure rises, remains high throughout the manoeuvre, and returns to its previous level at the end





Figure 2. Arterial blood pressure response and Korotkoff's sounds during Valsalva's manoeuvre.

(A) Sinusoidal response in normal patient.

(B) Absent overshoot in patient with autonomic dysfunction.

(C) Square wave response in patient with heart failure"



from AnesthesiaUK