Browsing by Author "Kattan, Eduardo"

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    Anestesia obstétrica en Chad. Volviendo a los orígenes
    (Sociedad de Anestesiologia de Chile, 2022) Ghiringhelli, Juan Pablo; López, Rodrigo; Catalán, Cynthia; Kattan, Eduardo; Urzúa, Miguel; Cruzat, Francisco
    © 2022 Authors. All rights reserved.Background: Most maternal deaths occur in low- and middle-income countries, with Chad being one of the countries with the most alarming figures. There aren't many reports of anesthetic management for cesarean delivery in these countries. Aim: To report the obstetrical anesthetic experience in a hospital in Chad, Africa in the context of an international cooperation project to reduce the global shortage of anesthesiologists. Material and Methods: Case series of pregnant woman who were admitted to the ward of the Good Samaritan University Hospital Complex. Results: Thirty-two cesarean sections were performed, all using spinal anesthesia. The median age was 22 years, seven of them being adolescents. In two cases sedation with ketamine was used due to insufficient level and in one case general anesthesia with halothane was converted due to total spinal diagnosis. In twelve patients the interruption was due to immediate maternal/fetal vital risk (emergency cesarean section), the main causes being fetal bradycardia and placental abruption. Three patients presented uterine inertia refractory to medical treatment and resolved with the B-Lynch technique. Two patients decided to have immediate skin-to-skin contact. Three neonates had to be resuscitated with positive pressure ventilation, one of them died. No operative deaths were reported in the patients who underwent c-section, but there was one maternal death due to severe preeclampsia and postpartum hemorrhage after vaginal delivery. No epidural analgesia was requested for labor. Conclusions: This individual report provides insight into a particular reality with very limited staff and resources.
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    Differential Cardiac Responses after Passive Leg Raising
    (2024) Castro, Ricardo; Kattan, Eduardo; Hernandez, Glenn; Bakker, Jan
    This study retrospectively examined the hemodynamic effects of passive leg raising (PLR) in mechanically ventilated patients during fluid removal before spontaneous breathing trials. In previous studies, we noticed varying cardiac responses after PLR completion, particularly in positive tests. Using a bioreactance monitor, we recorded and analyzed hemodynamic parameters, including stroke volume and cardiac index (CI), before and after PLR in post-acute ICU patients. We included 27 patients who underwent 60 PLR procedures. In preload-unresponsive patients, no significant CI changes were observed (CI_t-6 = 3.7 [2.6; 4.7] mL/min/m2 vs. CI_t9 = 3.3 [2.5; 3.4] mL/min/m2; p = 0.306), while in preload-responsive patients, two distinct CI response types to PLR were identified: a transient peak with immediate return to baseline (CI_t-6 = 2.7 [2.5; 3.1] mL/min/m2 vs. 3.3 [2.6; 3.8] L/min/m2; p = 0.119) and a sustained CI elevation lasting beyond the PLR maneuver (CI_t-6 = 2.8 [2.3; 2.9] L/min/m2 vs. 3.3 [2.8; 3.9] ml/min/m2; p = 0.034). The latter was particularly noted when Delta CI during PLR exceeded 25%. Our findings suggest that in certain preload-responsive patients, PLR can induce a more sustained increase in CI, indicating a possible persistent hemodynamic effect. This effect could be due to a combination of autotransfusion and sympathetic activation affecting venous return and vascular tone. Further research in larger cohorts and more comprehensive hemodynamic assessments are warranted to validate these observations and elucidate the possible underlying mechanisms.The Fluid unLoading On Weaning (FLOW) study was prospectively registered under the ID NCT04496583 on 2020-07-29 at ClinicalTrials.gov.
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    Doppler identified venous congestion in septic shock: protocol for an international, multi-centre prospective cohort study (Andromeda-VEXUS)
    (2023) Prager, Ross; Argaiz, Eduardo; Pratte, Michael; Rola, Philippe; Arntfield, Robert; Beaubien-Souligny, William; Denault, Andre Y.; Haycock, Korbin; Aguiar, Francisco Miralles; Bakker, Jan; Ospina Tascón, Gustavo A.; Orozco, Nicolas; Rochwerg, Bram; Lewis, Kimberley; Quazi, Ibrahim; Kattan, Eduardo; Hernandez, Glenn; Basmaji, John
    Introduction Venous congestion is a pathophysiological state where high venous pressures cause organ oedema and dysfunction. Venous congestion is associated with worse outcomes, particularly acute kidney injury (AKI), for critically ill patients. Venous congestion can be measured by Doppler ultrasound at the bedside through interrogation of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV) and intrarenal veins (IRV). The objective of this study is to quantify the association between Doppler identified venous congestion and the need for renal replacement therapy (RRT) or death for patients with septic shock.Methods and analysis This study is a prespecified substudy of the ANDROMEDA-SHOCK 2 (AS-2) randomised control trial (RCT) assessing haemodynamic resuscitation in septic shock and will enrol at least 350 patients across multiple sites. We will include adult patients within 4 hours of fulfilling septic shock definition according to Sepsis-3 consensus conference. Using Doppler ultrasound, physicians will interrogate the IVC, HV, PV and IRV 6-12 hours after randomisation. Study investigators will provide web-based educational sessions to ultrasound operators and adjudicate image acquisition and interpretation. The primary outcome will be RRT or death within 28 days of septic shock. We will assess the hazard of RRT or death as a function of venous congestion using a Cox proportional hazards model. Sub-distribution HRs will describe the hazard of RRT given the competing risk of death.Ethics and dissemination We obtained ethics approval for the AS-2 RCT, including this observational substudy, from local ethics boards at all participating sites. We will report the findings of this study through open-access publication, presentation at international conferences, a coordinated dissemination strategy by investigators through social media, and an open-access workshop series in multiple languages.Trial registration number NCT05057611.
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    Drug diluent and efficacy of methylene blue in septic shock: authors’ reply
    (2023) Ibarra Estrada, Miguel; Kattan, Eduardo; Aguirre Avalos, Guadalupe; Hernández P., Glenn
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    Expanding ICU facilities in a pandemic scenario
    (SOC MEDICA SANTIAGO, 2020) Andresen, Max; Born, Pablo; Kattan, Eduardo; Vera, Magdalena; Cataldo, Alejandro; Ruiz, Carolina; Bravo, Sebastian
    Our country is suffering the effects of the ongoing pandemic of coronavirus disease (COVID-19). Because the vulnerability of healthcare systems, especially the intensive care areas they can rapidly be overloaded. That challenge the ICUs simultaneously on multiple fronts making urgent to increase the number of beds, without lowering the standards of care. The purpose of this article is to discuss some aspects of the national situation and to provide recommendations on the organizational management of intensive care units such as isolation protocols, surge in ICU bed capacity, ensure adequate supplies, protect and train healthcare workers maintaining quality clinical management.
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    Exploring the relationship between capillary refill time, skin blood flow and microcirculatory reactivity during early resuscitation of patients with septic shock: a pilot study
    (2023) Contreras, Roberto; Hernandez, Glenn; Daniel Valenzuela, Emilio; Gonzalez, Cecilia; Ulloa, Rodrigo; Soto, Dagoberto; Castro, Ricardo; Guzman, Camila; Oviedo, Vanessa; Alegria, Leyla; Vidal, Diego; Morales, Sebastian; Adolfo Ospina-Tascon, Gustavo; Bakker, Jan; Kattan, Eduardo
    Capillary refill time (CRT), a costless and widely available tool, has emerged as a promising target to guide septic shock resuscitation. However, it has yet to gain universal acceptance due to its potential inter-observer variability. Standardization of CRT assessment may minimize this problem, but few studies have compared this approach with techniques that directly assess skin blood flow (SBF). Our objective was to determine if an abnormal CRT is associated with impaired SBF and microvascular reactivity in early septic shock patients. Twelve septic shock patients were subjected to multimodal perfusion and hemodynamic monitoring for 24 h. Three time-points (0, 1, and 24 h) were registered for each patient. SBF was measured by laser doppler. We performed a baseline SBF measurement and two microvascular reactivity tests: one with a thermal challenge at 44 & DEG;C and other with a vascular occlusion test. Ten healthy volunteers were evaluated to obtain reference values. The patients (median age 70 years) exhibited a 28-day mortality of 50%. Baseline CRT was 3.3 [2.7-7.3] seconds. In pooled data analysis, abnormal CRT presented a significantly lower SBF when compared to normal CRT [44 (13.3-80.3) vs 193.2 (99.4-285) APU, p = 0.0001]. CRT was strongly associated with SBF (R-2 0.76, p < 0.0001). An abnormal CRT also was associated with impaired thermal challenge and vascular occlusion tests. Abnormal CRT values observed during early septic shock resuscitation are associated with impaired skin blood flow, and abnormal skin microvascular reactivity. Future studies should confirm these results.
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    Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery
    (2024) Castro, Ricardo; Born, Pablo; Munoz, Felipe; Guzman, Camila; Kattan, Eduardo; Hernandez, Glenn; Bakker, Jan
    A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m2 (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients.
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    Hemodynamic phenotype-based, capillary refill time-targeted resuscitation in early septic shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial study protocol
    (2022) Kattan, Eduardo; Castro R.; Hernández P., Glenn; Bakker, Jan; Estenssoro E.; Ospina Tascón, Gustavo A.; Cavalcanti A.B.; De Backer D.; Vieillard-Baron A.; Teboul J.-L.
    © 2022 Associacao de Medicina Intensiva Brasileira - AMIB. All rights reserved.Background: Early reversion of sepsis-induced tissue hypoperfusion is essential for survival in septic shock. However, consensus regarding the best initial resuscitation strategy is lacking given that interventions designed for the entire population with septic shock might produce unnecessary fluid administration. This article reports the rationale, study design and analysis plan of the ANDROMEDA-2 study, which aims to determine whether a peripheral perfusion-guided strategy consisting of capillary refill time-targeted resuscitation based on clinical and hemodynamic phenotypes is associated with a decrease in a composite outcome of mortality, time to organ support cessation, and hospital length of stay compared to standard care in patients with early (< 4 hours of diagnosis) septic shock. Methods: The ANDROMEDA-2 study is a multicenter, multinational randomized controlled trial. In the intervention group, capillary refill time will be measured hourly for 6 hours. If abnormal, patients will enter an algorithm starting with pulse pressure assessment. Patients with pulse pressure less than 40mmHg will be tested for fluid responsiveness and receive fluids accordingly. In patients with pulse pressure > 40mmHg, norepinephrine will be titrated to maintain diastolic arterial pressure > 50mmHg. Patients who fail to normalize capillary refill time after the previous steps will be subjected to critical care echocardiography for cardiac dysfunction evaluation and subsequent management. Finally, vasopressor and inodilator tests will be performed to further optimize perfusion. A sample size of 1,500 patients will provide 88% power to demonstrate superiority of the capillary refill time-targeted strategy. Conclusions: If hemodynamic phenotype-based, capillary refill time-targeted resuscitation demonstrates to be a superior strategy, care processes in septic shock resuscitation can be optimized with bedside tools.
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    Knowing the ropes of vasopressor dosing: a focus on norepinephrine
    (2024) Kattan, Eduardo; Ibarra-Estrada, Miguel; Jung, Christian
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    Process-oriented metrics to provide feedback and assess the performance of students who are learning surgical procedures: The percutaneous dilatational tracheostomy case
    (TAYLOR & FRANCIS LTD, 2022) Jose Martinez, Juan; Galvez-Yanjari, Victor; de la Fuente, Rene; Kychenthal, Catalina; Kattan, Eduardo; Bravo, Sebastian; Munoz-Gama, Jorge; Sepulveda, Marcos
    Purpose Assessing competency in surgical procedures is key for instructors to distinguish whether a resident is qualified to perform them on patients. Currently, assessment techniques do not always focus on providing feedback about the order in which the activities need to be performed. In this research, using a Process Mining approach, process-oriented metrics are proposed to assess the training of residents in a Percutaneous Dilatational Tracheostomy (PDT) simulator, identifying the critical points in the execution of the surgical process. Materials and methods A reference process model of the procedure was defined, and video recordings of student training sessions in the PDT simulator were collected and tagged to generate event logs. Three process-oriented metrics were proposed to assess the performance of the residents in training. Results Although the students were proficient in classic metrics, they did not reach the optimum in process-oriented metrics. Only in 25% of the stages the optimum was achieved in the last session. In these stages, the four more challenging activities were also identified, which account for 32% of the process-oriented metrics errors. Conclusions Process-oriented metrics offer a new perspective on surgical procedures performance, providing a more granular perspective, which enables a more specific and actionable feedback for both students and instructors.
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    ProDeM: A Process-Oriented Delphi Method for systematic asynchronous and consensual surgical process modelling
    (ELSEVIER, 2023) Gonzalez-Lopez, Fernanda; Martin, Niels; de la Fuente, Rene; Galvez-Yanjari, Victor; Guzman, Javiera; Kattan, Eduardo; Sepulveda, Marcos; Muñoz Gama, Jorge
    Surgical process models support improving healthcare provision by facilitating communication and reasoning about processes in the medical domain. Modelling surgical processes is challenging as it requires integrating information that might be fragmented, scattered, and not process-oriented. These challenges can be faced by involving healthcare domain experts during process modelling. This paper presents ProDeM: a novel ProcessOriented Delphi Method for the systematic, asynchronous, and consensual modelling of surgical processes. ProDeM is an adaptable and flexible method that acknowledges that: (i) domain experts have busy calendars and might be geographically dispersed, and (ii) various elements of the process model need to be assessed to ensure model quality. The contribution of the paper is twofold as it outlines ProDeM, but also demonstrates its operationalisation in the context of a well-known surgical process. Besides showing the method's feasibility in practice, we also present an evaluation of the method by the experts involved in the demonstration.
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    Simulation-based training program for peripherally inserted central catheter placement. Randomized comparative study of in-person training with synchronous feedback versus distance training with asynchronous feedback
    (2024) Corvetto, Marcia A.; Kattan, Eduardo; Ramirez, Gaspar; Besa, Pablo; Abbott Cáceres, Eduardo Francisco; Zamorano Rivera, Elga del Carmen; Contreras Ibacache, Víctor; Altermatt, Fernando R.
    Simulation training that includes deliberate practice is effective for procedural skill training. Delivering feedback remotely and asynchronously has been examined for more cost-efficient training. This prospective randomized study aimed to compare 2 feedback techniques for simulation training: synchronous direct feedback versus asynchronous distance feedback (ASYNC). MethodsForty anesthesia and internal medicine residents were recruited after study approval by the institutional ethics committee. Residents reviewed instructional material on an online platform and performed a pretraining assessment (PRE) for peripherally inserted central catheter (PICC) placement. Each resident was then randomly assigned to 1 of 2 training types, practice with synchronous direct feedback (SYNC) or practice with ASYNC. Training consisted of four, 1-hour practice sessions; each was conducted once per week. Both groups underwent posttraining evaluation (POST). The PRE and POST assessments were videotaped and evaluated by 2 independent, blinded reviewers using a global rating scale. ResultsThirty-five residents completed the training program and both evaluations. Both groups had significantly improved global rating scale scores after 4 sessions. The SYNC group improved from 28 to 45 points (P < 0.01); the ASYNC group improved from 26.5 to 46 points (P < 0.01). We found no significant between-group differences for the PRE (P = 0.42) or POST assessments (P = 0.13). ConclusionThis simulation-based training program significantly improved residents' peripherally inserted central venous catheter placement skills using either modality. With these results, we are unable to demonstrate the superiority of synchronous feedback over ASYNC. Asynchronous feedback training modality represents a new, innovative approach for health care procedural skills training.
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    The emerging concept of fluid tolerance: A position paper
    (2022) Kattan, Eduardo; Castro, Ricardo; Miralles-Aguiar, Francisco; Hernandez, Glenn; Rola, Philippe
    Available online xxxx Fluid resuscitation is a core component of emergency and critical care medicine. While the focus of clinicians has largely been on detecting patients who would respond to fluid therapy, relatively little work has been done on assessing patients' tolerance to this therapy. In this article we seek to review the concept of fluid tolerance, propose a working definition, and introduce relevant clinical signals by which physicians can assess fluid tolerance, hopefully becoming a starting point for further research.
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    The seven Ts of capillary refill time: more than a clinical sign for septic shock patients
    (LIPPINCOTT WILLIAMS & WILKINS, 2020) Vera, Magdalena; Kattan, Eduardo; Castro, Ricardo; Hernandez, Glenn
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    Uso de la simulación clínica para entrenar equipos en el manejo de conflictos durante los cuidados en salud: una revisión sistemática exploratoria
    (2022) Putz, Francisca; Kattan, Eduardo; Maestre, Jose M.
    Y Objective: To assess and analyze the impact of clinical simulation as a training tool in healthcare teams ability to resolve and manage conflicts, through an exploratory systematic review.