Browsing by Author "Bruhn, Alejandro"

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    A deep look into the rib cage compression technique in mechanically ventilated patients: a narrative review
    (2022) Jalil Contreras, Yorschua Frederick; Damiani, L. Felipe; Basoalto, Roque; Bachmman, María Consuelo; Bruhn, Alejandro
    Defective management of secretions is one of the most frequent complications in invasive mechanically ventilated patients. Clearance of secretions through chest physiotherapy is a critical aspect of the treatment of these patients. Manual rib cage compression is one of the most practiced chest physiotherapy techniques in ventilated patients; however, its impact on clinical outcomes remains controversial due to methodological issues and poor understanding of its action. In this review, we present a detailed analysis of the physical principles involved in rib cage compression technique performance, as well as the physiological effects observed in experimental and clinical studies, which show that the use of brief and vigorous rib cage compression, based on increased expiratory flows (expiratory-inspiratory airflow difference of > 33L/minute), can improve mucus movement toward the glottis. On the other hand, the use of soft and gradual rib cage compression throughout the whole expiratory phase does not impact the expiratory flows, resulting in ineffective or undesired effects in some cases. More physiological studies are needed to understand the principles of the rib cage compression technique in ventilated humans. However, according to the evidence, rib cage compression has more potential benefits than risks, so its implementation should be promoted.
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    Airway humidification practices in Chilean intensive care units
    (SOC MEDICA SANTIAGO, 2012) Retamal, Jaime; Castillo, Juan; Bugedo, Guillermo; Bruhn, Alejandro
    Airway humidification practices in Chilean intensive care units Background: In patients with an artificial airway, inspired gases can be humidified and heated using a passive (heat and moisture exchange filter - HMEF), or an active system (heated humidifier). Aim: To assess how humidification is carried out and what is the usual clinical practice in this field in Chilean intensive care units (ICUs). Material and Methods: A specific survey to evaluate humidification system features as well as caregivers' preferences regarding humidification systems, was carried out on the same day in all Chilean ICUs. Results: Fifty-five ICUs were contacted and 44 of them completed the survey. From a total of 367 patients, 254 (69%) required humidification because they were breathing through an artificial airway. A heated humidifier was employed only in 12 patients (5%). Forty-three ICUs (98%) used HMEF as their routine humidification system. In 52% of surveyed ICUs, heated humidifiers were not available. Conclusions: In Chile the main method to humidify and heat inspired gases in patients with an artificial airway is the HMEE Although there are clear indications for the use of heated humidifiers, they are seldom employed. (Rev Med Chile 2012; 140: 1425-1430).
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    An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock
    (2008) Castro López, Ricardo; Regueira Heskia, Tomás; Aguirre Zúniga, Marcia Lorena; Llanos Valdés, Osvaldo Pablo; Bruhn, Alejandro; Bugedo Tarraza, Guillermo; Dougnac Labatut, Alberto; Castillo Fuenzalida, Luis Benito; Andresen Hernández, Max; Hernández P., Glenn
    Background. Septic shock is highly lethal. We recently implemented an algorithm (advanced resuscitation algorithm for septic shock, ARAS 1) with a global survival of 67%, but with a very high mortality (72%) in severe cases [norepinephrine (NE) requirements >0.3 µg/kg/min for mean arterial pressure ≥70 mmHg]. As new therapies with different levels of evidence were proposed [steroids, drotrecogin alpha, high-volume hemofiltration (HVHF)], we incorporated them according to severity (NE requirements; algorithm ARAS-2), and constructed a multidisciplinary team to manage these patients from the emergency room (ER) to the ICU. The aim of this study was to compare the outcome of severe septic shock patients under both protocols. Methods. Adult patients with severe septic shock were enrolled consecutively and managed prospectively with ARAS1 (1999-2001), and ARAS-2 (2002-05). ARAS-2 incorporates HVHF for intractable shock. Results. Thirty-three patients were managed with each protocol, without statistical differences in baseline demographics, APACHE II (22.2 vs 23.8), SOFA (11.4 vs 12.7) and NE peak levels (0.62 vs 0.8 µg/kg/min). The 28-day mortality and epinephrine use were higher with ARAS-1 (72.7% vs 48.5%; 87.9% vs 18.2 %); and low-dose steroids (35.9% vs 72.7%), drotrecogin (0 vs 15 %) and HVHF use (3.0% vs 39.4%) were higher for ARAS-2 (P<0.05 for all). Conclusion. Management of severe septic shock with a multidisciplinary team and an updated protocol (according to the best current evidence), with precise entry criteria for every intervention at different stages of severity, may improve survival in these patients. Multidisciplinary management, rationalization of the use of vasoactives and rescue therapy based on HVHF instead of epinephrine may have contributed to these results. Management of severe septic shock with these kinds of algorithms is feasible and should be encouraged.
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    Can venous-to-arterial carbon dioxide differences reflect microcirculatory alterations in patients with septic shock?
    (2016) Arango Dávila, C.; De Backer, D.; Ospina Tascón, G.; Umaña, M.; Bermúdez, W.; Bautista Rincón, D.; Valencia, J.; Madriñán, H.; Hernández P., Glenn; Bruhn, Alejandro
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    Cateterización venosa suprahepática en cuatro casos de shock séptico severo
    (2001) Inzunza Pérez, Carlos; Cornu A., M.; Bruhn, Alejandro; Castillo Fuenzalida, Luis Benito; Bugedo Tarraza, Guillermo; Acuña C., D.; Medeiros U., S.; Hernández P., Glenn
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    Challenges and limitations of using ventilator-free days as an outcome in critical care trials
    (2024) Bruhn, Alejandro; Kattan Tala, Eduardo José; Biasi Cavalcanti, Alexandre
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    Clinical characteristics, systemic complications, and in-hospital outcomes for patients with COVID-19 in Latin America. LIVEN-Covid-19 study: A prospective, multicenter, multinational, cohort study
    (PUBLIC LIBRARY SCIENCE, 2022) Reyes, Luis F.; Bastidas, Alirio; Narvaez, Paula O.; Parra-Tanoux, Daniela; Fuentes, Yuli, V; Serrano-Mayorga, Cristian C.; Ortiz, Valentina; Caceres, Eder L.; Ospina-Tascon, Gustavo; Diaz, Ana M.; Jibaja, Manuel; Vera, Magdalena; Silva, Edwin; Gorordo-Delsol, Luis Antonio; Maraschin, Francesca; Varon-Vega, Fabio; Buitrago, Ricardo; Poveda, Marcela; Saucedo, Lina M.; Estenssoro, Elisa; Ortiz, Guillermo; Nin, Nicolas; Calderon, Luis E.; Montano, Gina S.; Chaar, Aldair J.; Garcia, Fernanda; Ramirez, Vanessa; Picoita, Fabricio; Pelaez, Cristian; Unigarro, Luis; Friedman, Gilberto; Cucunubo, Laura; Bruhn, Alejandro; Hernandez, Glenn; Martin-Loeches, Ignacio
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    Combination of arterial lactate levels and venous-arterial CO2 to arterial-venous O-2 content difference ratio as markers of resuscitation in patients with septic shock
    (2015) Ospina-Tascon, Gustavo A.; Umana, Mauricio; Bermudez, William; Bautista-Rincon, Diego F.; Hernández P., Glenn; Bruhn, Alejandro; Granados, Marcela; Salazar, Blanca; Arango-Dávila, César; De Backer, Daniel
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    Continuous prolonged prone positioning in COVID-19-related ARDS: a multicenter cohort study from Chile
    (2022) Cornejo, Rodrigo A.; Montoya, Jorge; Gajardo, Abraham I. J.; Graf, Jerónimo; Alegría Vargas, Leyla; Baghetti, Romyna; Irarrázaval, Anita; Santis, César; Pavez, Nicolás; Leighton, Sofía; Tomicic, Vinko; Morales, Daniel; Ruiz Balart, Carolina; Navarrete, Pablo; Vargas, Patricio; Gálvez, Roberto; Espinosa, Victoria; Lazo, Marioli; Pérez-Araos, Rodrigo A.; Garay, Osvaldo; Sepúlveda, Patrick; Martinez, Edgardo; Bruhn, Alejandro; The SOCHIMI Prone-COVID-19 Group; Pontificia Universidad Católica de Chile. Escuela de Medicina
    Background Prone positioning is currently applied in time-limited daily sessions up to 24 h which determines that most patients require several sessions. Although longer prone sessions have been reported, there is scarce evidence about the feasibility and safety of such approach. We analyzed feasibility and safety of a continuous prolonged prone positioning strategy implemented nationwide, in a large cohort of COVID-19 patients in Chile. Methods: Retrospective cohort study of mechanically ventilated COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS), conducted in 15 Intensive Care Units, which adhered to a national protocol of continuous prone sessions  ≥ 48 h and until PaO2:FiO2 increased above 200 mm Hg. The number and extension of prone sessions were registered, along with relevant physiologic data and adverse events related to prone positioning. The cohort was stratified according to the first prone session duration: Group A, 2–3 days; Group B, 4–5 days; and Group C, > 5 days. Multivariable regression analyses were performed to assess whether the duration of prone sessions could impact safety. Results: We included 417 patients who required a first prone session of 4 (3–5) days of whom 318 (76.3%) received only one session. During the first prone session the main adverse event was grade 1–2 pressure sores in 97 (23.9%) patients; severe adverse events were infrequent with 17 non-scheduled extubations (4.2%). 90-day mortality was 36.2%. Ninety-eight patients (24%) were classified as group C; they exhibited a more severe ARDS at baseline, as reflected by lower PaO2:FiO2 ratio and higher ventilatory ratio, and had a higher rate of pressure sores (44%) and higher 90-day mortality (48%). However, after adjustment for severity and several relevant confounders, prone session duration was not associated with mortality or pressure sores. Conclusions: Nationwide implementation of a continuous prolonged prone positioning strategy for COVID-19 ARDS patients was feasible. Minor pressure sores were frequent but within the ranges previously described, while severe adverse events were infrequent. The duration of prone session did not have an adverse effect on safety.
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    Dexmedetomidine ameliorates gut lactate production and impairment of exogenous lactate clearance in an endotoxic sheep model
    (2015) Hernández P., Glenn; Tapia, Pablo; Bruhn, Alejandro; Soto, Dagoberto; Alegría, Leyla; Jarufe Cassis, Nicolás; Menchaca, Rodrigo; Meissner, Arturo; Vives, María Ignacia; Ospina Tascón, Gustavo A.; Luengo, Cecilia; Bakker, Jan
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    Does Regional Lung Strain Correlate With Regional Inflammation in Acute Respiratory Distress Syndrome During Nonprotective Ventilation? An Experimental Porcine Study
    (2018) Retamal Montes, Jaime; Hurtado Sepúlveda, Daniel; Villarroel, Nicolás; Bruhn, Alejandro; Bugedo Tarraza, Guillermo; Amato, Marcelo; Costa, Eduardo L. V.; Hedenstierna, Goran; Larsson, Anders; Borges, Joäo Batista
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    Does the use of high PEEP levels prevent ventilator-induced lung injury?
    (2017) Bugedo Tarraza, Guillermo; Retamal Montes, Jaime; Bruhn, Alejandro
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    Driving pressure : a marker of severity, a safety limit, or a goal for mechanical ventilation?
    (2017) Bugedo Tarraza, Guillermo; Retamal Montes, Jaime; Bruhn, Alejandro
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    Early and severe impairment of lactate clearance in endotoxic shock is not related to liver hypoperfusion: preliminary report
    (2014) Tapia, Pablo; Soto, Dagoberto; Bruhn, Alejandro; Regueira Heskia, Tomás; Jarufe Cassis, Nicolás; Alegría, Leyla; Bachler, J. P.; Leon, F.; Vicuña, C.; Hernández P., Glenn
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    Effect of a lung rest strategy during ECMO in a porcine acute lung injury model
    (2015) Araos, J.; Tapia, Pablo; Alegría, Leyla; García Cañete, Patricia; Rodríguez, F.; Amthauer, M.; Castro, G.; Soto, Dagoberto; Damiani Rebolledo, L. Felipe; Bugedo Tarraza, Guillermo; Bruhn, Alejandro; Cruces, Pablo; Salomon, Tatiana; Erranz, B.; Carreño, P.; Medina, T.
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    Effect of positive end expiratory pressure on lung injury and haemodynamics during experimental acute respiratory distress syndrome treated with extracorporeal membrane oxygenation and near-apnoeic ventilation
    (2021) Araos, Joaquin; Alegría Vargas, Leyla; Garcia, Aline; Cruces, Pablo; Soto Muñoz, Dagoberto Igor; Erranz, Benjamín; Salomon, Tatiana; Medina, Tania; García Valdes, Patricio Hernán; Dubo, Sebastian; Bachmann Barron, María Consuelo; Basoalto Escobar, Roque Ignacio; Valenzuela, Emilio Daniel; Rovegno Echavarría, Maximiliano David; Vera Alarcón, María Magdalena; Retamal Montes, Jaime; Cornejo Rosas, Rodrigo Alfredo; Bugedo Tarraza, Guillermo; Bruhn, Alejandro
    Background: Lung rest has been recommended during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Whether positive end-expiratory pressure (PEEP) confers lung protection during ECMO for severe ARDS is unclear. We compared the effects of three different PEEP levels whilst applying near-apnoeic ventilation in a model of severe ARDS treated with ECMO. Methods: Acute respiratory distress syndrome was induced in anaesthetised adult male pigs by repeated saline lavage and injurious ventilation for 1.5 h. After ECMO was commenced, the pigs received standardised near-apnoeic ventilation for 24 h to maintain similar driving pressures and were randomly assigned to PEEP of 0, 10, or 20 cm H2O (n¼7 per group). Respiratory and haemodynamic data were collected throughout the study. Histological injury was assessed by a pathologist masked to PEEP allocation. Lung oedema was estimated by wet-to-dry-weight ratio. Results: All pigs developed severe ARDS. Oxygenation on ECMO improved with PEEP of 10 or 20 cm H2O, but did not in pigs allocated to PEEP of 0 cm H2O. Haemodynamic collapse refractory to norepinephrine (n¼4) and early death (n¼3) occurred after PEEP 20 cm H2O. The severity of lung injury was lowest after PEEP of 10 cm H2O in both dependent and non-dependent lung regions, compared with PEEP of 0 or 20 cm H2O. A higher wet-to-dry-weight ratio, indicating worse lung injury, was observed with PEEP of 0 cmH2O. Histological assessment suggested that lung injury was minimised with PEEP of 10 cm H2O. Conclusions: During near-apnoeic ventilation and ECMO in experimental severe ARDS, 10 cm H2O PEEP minimised lung injury and improved gas exchange without compromising haemodynamic stability.
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    Effects of dexmedetomidine and esmolol on systemic hemodynamics and exogenous lactate clearance in early experimental septic shock
    (2016) Hernández P., Glenn; Tapia, Pablo; Alegría, Leyla; Soto, Dagoberto; Jarufe Cassis, Nicolás; Achurra Tirado, Pablo; Rebolledo, Rolando; Bruhn, Alejandro; Castro, Ricardo; Kattan Tala, Eduardo José; Bakker, Jan; Luengo, Cecilia; Gomez, Jussara; Ospina Tascón, Gustavo
    Abstract Background Persistent hyperlactatemia during septic shock is multifactorial. Hypoperfusion-related anaerobic production and adrenergic-driven aerobic generation together with impaired lactate clearance have been implicated. An excessive adrenergic response could contribute to persistent hyperlactatemia and adrenergic modulation might be beneficial. We assessed the effects of dexmedetomidine and esmolol on hemodynamics, lactate generation, and exogenous lactate clearance during endotoxin-induced septic shock. Methods Eighteen anesthetized and mechanically ventilated sheep were subjected to a multimodal hemodynamic/perfusion assessment including hepatic and portal vein catheterizations, total hepatic blood flow, and muscle microdialysis. After monitoring, all received a bolus and continuous infusion of endotoxin. After 1 h they were volume resuscitated, and then randomized to endotoxin-control, endotoxin-dexmedetomidine (sequential doses of 0.5 and 1.0 μg/k/h) or endotoxin-esmolol (titrated to decrease basal heart rate by 20 %) groups. Samples were taken at four time points, and exogenous lactate clearance using an intravenous administration of sodium L-lactate (1 mmol/kg) was performed at the end of the experiments. Results Dexmedetomidine and esmolol were hemodynamically well tolerated. The dexmedetomidine group exhibited lower epinephrine levels, but no difference in muscle lactate. Despite progressive hypotension in all groups, both dexmedetomidine and esmolol were associated with lower arterial and portal vein lactate levels. Exogenous lactate clearance was significantly higher in the dexmedetomidine and esmolol groups. Conclusions Dexmedetomidine and esmolol were associated with lower arterial and portal lactate levels, and less impairment of exogenous lactate clearance in a model of septic shock. The use of dexmedetomidine and esmolol appears to be associated with beneficial effects on gut lactate generation and lactate clearance and exhibits no negative impact on systemic hemodynamics.Abstract Background Persistent hyperlactatemia during septic shock is multifactorial. Hypoperfusion-related anaerobic production and adrenergic-driven aerobic generation together with impaired lactate clearance have been implicated. An excessive adrenergic response could contribute to persistent hyperlactatemia and adrenergic modulation might be beneficial. We assessed the effects of dexmedetomidine and esmolol on hemodynamics, lactate generation, and exogenous lactate clearance during endotoxin-induced septic shock. Methods Eighteen anesthetized and mechanically ventilated sheep were subjected to a multimodal hemodynamic/perfusion assessment including hepatic and portal vein catheterizations, total hepatic blood flow, and muscle microdialysis. After monitoring, all received a bolus and continuous infusion of endotoxin. After 1 h they were volume resuscitated, and then randomized to endotoxin-control, endotoxin-dexmedetomidine (sequential doses of 0.5 and 1.0 μg/k/h) or endotoxin-esmolol (titrated to decrease basal heart rate by 20 %) groups. Samples were taken at four time points, and exogenous lactate clearance using an intravenous administration of sodium L-lactate (1 mmol/kg) was performed at the end of the experiments. Results Dexmedetomidine and esmolol were hemodynamically well tolerated. The dexmedetomidine group exhibited lower epinephrine levels, but no difference in muscle lactate. Despite progressive hypotension in all groups, both dexmedetomidine and esmolol were associated with lower arterial and portal vein lactate levels. Exogenous lactate clearance was significantly higher in the dexmedetomidine and esmolol groups. Conclusions Dexmedetomidine and esmolol were associated with lower arterial and portal lactate levels, and less impairment of exogenous lactate clearance in a model of septic shock. The use of dexmedetomidine and esmolol appears to be associated with beneficial effects on gut lactate generation and lactate clearance and exhibits no negative impact on systemic hemodynamics.
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    Effects of dobutamine on intestinal microvascular blood flow heterogeneity and O-2 extraction during septic shock
    (2017) Ospina, G; Marin, A.; Echeverri, G; Bermúdez, W; Madriñán, H; Valencia, J; Quiñones, E; Rodríguez, F; Bruhn, Alejandro; Hernández P., Glenn; Marulanda, A; Arango, C; De Backer, D
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    Effects of dobutamine on intestinal microvascular blood flow heterogeneity and O2 extraction during septic shock
    (2017) Ospina-Tascón, Gustavo A.; García Marín, Alberto F.; Echeverri, Gabriel J.; Bermúdez, William F.; Madriñán-Navia, Humberto; Valencia, Juan David; Quiñones, Edgardo; Rodríguez, Fernando; Bruhn, Alejandro; Hernández P., Glenn; Marulanda, Angela; Arango-Dávila, César A.; De Backer, Daniel
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    Effects of dobutamine on systemic, regional and microcirculatory perfusion parameters in septic shock: a randomized, placebo-controlled, double-blind, crossover study
    (2013) Hernández P., Glenn; Bruhn, Alejandro; Luengo Messen, Cecilia; Regueira Heskia, Tomás; Kattan Tala, Eduardo José; Fuentealba, Andrea; Florez, Jorge; Castro López, Ricardo; Aquevedo Salazar, Andrés Fernando; Pairumani, Ronald; Mc-Nab Martin, Paul Andrew; Ince, Can