Comparação dos efeitos hemodinâmicos da infusão de cristaloides em velocidade rápida e lenta em pacientes críticos
Data
2024-03-25
Autores
Tomotani, Daniere Yurie Vieira 
Orientadores
Machado, Flávia Ribeiro
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Objetivo: O objetivo primário desse estudo é comparar o efeito da infusão de cristaloides para expansão volêmica feitos em velocidade lenta ou rápida na pressão arterial e em outros parâmetros hemodinâmicos e de perfusão tecidual. Métodos: Tratou-se de um estudo observacional com amostra de conveniência em nove centros participantes do estudo BaSICS, um ensaio clínico randomizado que comparou duas velocidades diferentes de infusão de fluidos de ressuscitação em pacientes graves internados em UTI. Foram incluídos pacientes randomizados previamente para o BaSICS que estivessem com monitorização de pressão venosa central (PVC) e pressão arterial invasiva. Foram excluídos os pacientes que necessitaram de infusão de mais que 500 ml de fluidos ou nos quais houvesse modificações de conduta durante o período de observação. As variáveis hemodinâmicas foram coletadas imediatamente antes da infusão e a cada 30 min até 60 min após o término da infusão, totalizando 2,5 horas de observação no grupo de velocidade lenta e 1,5 horas no grupo de velocidade rápida. As variáveis de perfusão tecidual imediatamente antes e após o término do protocolo. O desfecho primário foi a diferença ajustada na pressão arterial média (PAM) nos diferentes momentos (T0, T1, T2 e T3). A análise principal foi feita por meio de modelo misto ajustado por dose de noradrenalina basal, momento e grupo de intervenção (lento e rápido), com efeito randômico do paciente. Resultados: Um total de 146 pacientes completaram o estudo (grupo lento: 71, grupo rápido: 75). Não houve diferença no efeito marginal global na PAM, com uma diferença entre a velocidade rápida e a velocidade lenta de 1,1 mmHg [intervalo de confiança (IC) 95%: -2,3 mmHg a 4,6 mmHg; p = 0,52]. Não houve diferença entre os grupos no tocante a frequência cardíaca e nas variáveis de perfusão. A análise do efeito marginal global mostrou aumento da PVC com a velocidade rápida com uma diferença de 1,4 mmHg (IC 95%: 0,1 mmHg a 2,7 mmHg; p = 0,04). No subgrupo de pacientes onde foi mensurado o débito cardíaco (DC), a análise do efeito marginal global sobre o doente médio mostrou aumento do DC com a velocidade rápida com uma diferença de 1,78 L/min (IC 95%: 0,08 L/min a 3,48 L/min; p = 0,04). Conclusão: Em paciente de terapia intensiva submetidos a expansão volêmica, a infusão de cristaloides na velocidade lenta e rápida não levou a diferenças nos valores da PAM ou de perfusão tecidual, mas observamos aumento de DC e da PVC nos pacientes que receberam infusão de cristaloides em velocidade rápida.
Objective: The primary objective of this study is to compare the effects of crystalloid infusion for volume expansion performed at slow or fast rates on blood pressure and other hemodynamic and tissue perfusion parameters. Methods: This was an observational study in a subset of nine sites participating in the BaSICS study, a randomized clinical trial that compared two different infusion rates of fluid resuscitation in critically ill patients admitted to the ICU. We included patients previously randomized to BaSICS who were monitored with a central venous pressure (CVP) and invasive blood pressure. Patients who required an infusion of more than 500 ml of fluids or in whom there was a change in management during the observation period were excluded. Hemodynamic variables were collected immediately before the infusion and every 30 min until 60 min after the end of the infusion, totaling 2.5 hours of observation in the slow rate group and 1.5 hours in the fast rate group. We collected perfusion variables immediately before and after the end of the protocol. The primary outcome was the adjusted difference in mean arterial pressure (MAP) at different time points (T0, T1, T2 and T3). The main analysis was run using a mixed model adjusted for baseline norepinephrine dose, time and intervention group (slow and fast), with patient as intercept. Results: We included 146 patients in the study (slow group: 71, fast group: 75). There was no significant difference in global marginal effect on MAP, with a difference between fast speed and slow speed of 1.1 mmHg [95% confidence interval (CI): -2.3 mmHg to 4.6 mmHg; p = 0.52]. There was no difference between groups in heart rate and perfusion variables. Analysis of the overall marginal effect showed an increase in CVP in the fast rate group with fast rate with a difference of 1.4 mmHg (95% CI: 0.1 mmHg to 2.7 mmHg; p = 0.04). In the subgroup of patients where cardiac output (CO) was measured, an overall marginal effect analysis on the average patient showed an increase in cardiac output with fast velocity with a difference of 1.78 L/min (95% CI: 0.08 L/min to 3.48 L/min; p = 0.04). Conclusion: In intensive care patients undergoing volume expansion, crystalloid infusion at slow and fast speed did not lead to differences in MAP or tissue perfusion values, but we observed an increase in CO and CVP in patients who received crystalloid infusion at fast speed.
Objective: The primary objective of this study is to compare the effects of crystalloid infusion for volume expansion performed at slow or fast rates on blood pressure and other hemodynamic and tissue perfusion parameters. Methods: This was an observational study in a subset of nine sites participating in the BaSICS study, a randomized clinical trial that compared two different infusion rates of fluid resuscitation in critically ill patients admitted to the ICU. We included patients previously randomized to BaSICS who were monitored with a central venous pressure (CVP) and invasive blood pressure. Patients who required an infusion of more than 500 ml of fluids or in whom there was a change in management during the observation period were excluded. Hemodynamic variables were collected immediately before the infusion and every 30 min until 60 min after the end of the infusion, totaling 2.5 hours of observation in the slow rate group and 1.5 hours in the fast rate group. We collected perfusion variables immediately before and after the end of the protocol. The primary outcome was the adjusted difference in mean arterial pressure (MAP) at different time points (T0, T1, T2 and T3). The main analysis was run using a mixed model adjusted for baseline norepinephrine dose, time and intervention group (slow and fast), with patient as intercept. Results: We included 146 patients in the study (slow group: 71, fast group: 75). There was no significant difference in global marginal effect on MAP, with a difference between fast speed and slow speed of 1.1 mmHg [95% confidence interval (CI): -2.3 mmHg to 4.6 mmHg; p = 0.52]. There was no difference between groups in heart rate and perfusion variables. Analysis of the overall marginal effect showed an increase in CVP in the fast rate group with fast rate with a difference of 1.4 mmHg (95% CI: 0.1 mmHg to 2.7 mmHg; p = 0.04). In the subgroup of patients where cardiac output (CO) was measured, an overall marginal effect analysis on the average patient showed an increase in cardiac output with fast velocity with a difference of 1.78 L/min (95% CI: 0.08 L/min to 3.48 L/min; p = 0.04). Conclusion: In intensive care patients undergoing volume expansion, crystalloid infusion at slow and fast speed did not lead to differences in MAP or tissue perfusion values, but we observed an increase in CO and CVP in patients who received crystalloid infusion at fast speed.
Descrição
Citação
TOMOTANI, Daniere Yurie Vieira. Comparação dos efeitos hemodinâmicos da infusão de cristaloides em velocidade rápida e lenta em pacientes críticos. 2024. 81 f. Tese (Doutorado em Medicina Translacional) - Escola Paulista de Medicina. Universidade Federal de São Paulo (UNIFESP). São Paulo, 2024.