GRAF SANTOS, JERÓNIMO
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GRAF SANTOS, JERÓNIMO
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jgraf@udd.cl
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7102778326

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Intrathoracic blood volume versus pulmonary artery occlusion pressure as estimators of cardiac preload in critically ill patients

2005-01-01 , Tomicic F, Vinko , GRAF SANTOS, JERÓNIMO , Echevarría O, Ghislaine , Espinoza R, Mauricio , Abarca Z, Juan , Montes S, José Miguel , Torres M, Javier , Núñez U, Gastón , Guerrero P, Julia , Luppi N, Mario , Canals L, Claudio

Background: Monitoring of cardiac preload by determination of pulmonary artery occlusion pressure (PAOP) has been traditionally used to guide fluid therapy to optimize cardiac output (CO). Since factors such as intrathoracic pressure and ventricular compliance may modify PAOP, volumetric estimators of preload have been developed. The PiCCO system is able to measure CO and intrathoracic blood volume (ITBV) by transpulmonary thermodilution. Aim: To compare a volumetric (ITBV) versus a pressure (PAOP) determination to accurately estimate cardiac preload in severely ill patients. Patients and Methods: From June 2001 to October 2003, 22 mechanically ventilated patients with hemodynamic instability underwent hemodynamic monitoring with pulmonary artery catheter (PAC) and PiCCO system. ITBV index (ITBVI), PAOP and CI were measured simultaneously by both methods. One hundred thirty eight deltas (Δ) were obtained from the difference of ITBVI, PAOP, CI-PAC and CI-PiCCO between 6-12 am and 6-12 pm. Linear regression analysis of Δ ITBVI versus Δ CI-PiCCO and Δ PAOP versus Δ CI-PAC were made. Results: Mean age of patients was 60.8 ± 19.4 years. APACHE II was 23.9 ± 7. Fifteen patients met criteria for acute respiratory distress syndrome (ARDS). Delta ITBVI significantly correlated with Δ CI-PiCCO (r=0.54; 95% confidence interval = 0.41-0.65; p <0.01). There was no correlation between Δ PAOP and Δ CI-PAC. Conclusion: ITBVI correlated better with CI than PAOP, and therefore it seems to be a more accurate estimator of preload in unstable, mechanically ventilated patients.

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Hemodynamic and Pulmonary Permeability Characterization of Hantavirus Cardiopulmonary Syndrome by Transpulmonary Thermodilution

2019 , LOPEZ HERNANDEZ, RENE RAMON , Rodrigo Pérez-Araos , Álvaro Salazar , Ana L. Ulloa , VIAL COX, MARIA CECILIA , VIAL CLARO, PABLO AGUSTIN , GRAF SANTOS, JERÓNIMO

Hantavirus cardiopulmonary syndrome (HCPS) is characterized by capillary leak, pulmonary edema (PE), and shock, which leads to death in up to 40% of patients. Treatment is supportive, including mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO). Hemodynamic monitoring is critical to titrate therapy and to decide ECMO support. Transpulmonary thermodilution (TPTD) provides hemodynamic and PE data that have not been systematically used to understand HCPS pathophysiology. We identified 11 HCPS patients monitored with TPTD: eight on MV, three required ECMO. We analyzed 133 measurements to describe the hemodynamic pattern and its association with PE. The main findings were reduced stroke volume, global ejection fraction (GEF), and preload parameters associated with increased extravascular lung water and pulmonary vascular permeability compatible with hypovolemia, myocardial dysfunction, and increased permeability PE. Lung water correlated positively with heart rate (HR, r = 0.20) and negatively with mean arterial pressure (r = −0.27) and GEF (r = −0.36), suggesting that PE is linked to hemodynamic impairment. Pulmonary vascular permeability correlated positively with HR (r = 0.31) and negatively with cardiac index (r = −0.49), end-diastolic volume (r = −0.48), and GEF (r = −0.40), suggesting that capillary leak contributes to hypovolemia and systolic dysfunction. In conclusion, TPTD data suggest that in HCPS patients, increased permeability leads to PE, hypovolemia, and circulatory impairment.

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Platelet Count in Patients with Mild Disease at Admission is Associated with Progression to Severe Hantavirus Cardiopulmonary Syndrome

2019 , LOPEZ HERNANDEZ, RENE RAMON , Mario Calvo , VIAL COX, MARIA CECILIA , Marcela Ferrés , GRAF SANTOS, JERÓNIMO , Gregory Mertz , Analía Cuiza , Begonia Agüero , Dante Aguilera , Diego Araya , Ignacia Pailamilla , Flavia Paratori , Víctor Torres-Torres , VIAL CLARO, PABLO AGUSTIN , DELGADO BECERRA, OROZIMBA IRIS

Background: Hantavirus cardiopulmonary syndrome (HCPS) has a mortality up to 35–40% and its treatment is mainly supportive. A variable to predict progression from mild to severe disease is unavailable. This study was performed in patients with documented infection by Andes orthohantavirus, and the aim was to find a simple variable to predict progression to moderate/severe HCPS in patients with mild disease at admission. Methods: We performed a retrospective analysis of 175 patients between 2001 and 2018. Patients were categorized into mild, moderate, and severe disease according to organ failure and advanced support need at hospital admission (e.g., mechanical ventilation, vasopressors). Progression to moderate/severe disease was defined accordingly. Clinical and laboratory variables associated with progression were explored. Results: Forty patients with mild disease were identified; 14 of them progressed to moderate/severe disease. Only platelet count was different between those who progressed versus those that did not (37 (34–58) vs. 83 (64–177) K/mm3, p < 0.001). A ROC curve analysis showed an AUC = 0.889 (0.78–1.0) p < 0.001, with a platelet count greater than 115K /mm3 ruling out progression to moderate/severe disease. Conclusions: In patients with mild disease at presentation, platelet count could help to define priority of evacuation to tertiary care centers.

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Reliability of transpulmonary pressure-time curve profile to identify tidal recruitment/hyperinflation in experimental unilateral pleural effusion

2017 , P. Formenti , M. Umbrello , GRAF SANTOS, JERÓNIMO , A. B. Adams , D. J. Dries , J. J. Marini

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Survival of Critically Ill Oncologic Patients Requiring Invasive Ventilatory Support: A Prospective Comparative Cohort Study With Nononcologic Patients

2019 , Rene López , Suraj Rajesh Samtani , Jose Miguel Montes , PEREZ ARAOS, RODRIGO ALEJANDRO , Maria Jose Martin , Alvaro Salazar , Jeronimo Graf

PURPOSE Cancer is in the process of changing to become a chronic disease; therefore, an increasing number of oncologic patients (OPs) are being admitted to intensive care units (ICUs) for supportive care of disease or therapy-related complications. We compare the short- and long-term outcomes of critically ill mechanically ventilated OPs with those of their nononcologic counterparts. PATIENTS AND METHODS We performed a prospective study of patients admitted to our ICU between October 2017 and February 2019. Demographic, physiologic, laboratory, clinical, and treatment data were obtained. The primary outcome was survival at 28 days and at the end of the follow-up period. Secondary outcomes were survival according to acute severity scoring (Acute Physiology and Chronic Health Evaluation II score), Eastern Cooperative Oncology Group (ECOG) performance status, and Charlson comorbidity index. RESULTS A total of 1,490 patients were admitted during the study period; 358 patients (24%) were OPs, and 100 of these OPs were supported with mechanical ventilation. Seventy-three percent of OPs had an ECOG performances status of 0 or 1, and 90% had solid tumors. Reason for admission to the ICU was postoperative admission in 44 patients and neutropenic infection in 10 patients. The follow-up period was 148 days (range, 42 to 363 days). Survival at 28 days was similar between OPs and nononcologic patients and associated with the Acute Physiology and Chronic Health Evaluation II score. However, long-term survival was lower in OPs compared with nononcologic patients (52% v 76%, respectively; P < .001) and associated with poor ECOG performance status. CONCLUSION Short-term survival of critically ill, mechanically ventilated OPs is similar to that of their nononcologic counterparts and is determined by the severity of the critical illness.

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Bedside lung volume measurement for estimation of alveolar recruitment

2012 , GRAF SANTOS, JERÓNIMO

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Minute ventilation to carbon dioxide production ratio is a simple and non-invasive index of ventilatory inefficiency in mechanically ventilated patients: proof of concept

2017 , René López , CAVIEDES SOTO, IVAN RICARDO , Jerónimo Graf

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Comment on Tusman et al.: Validation of Bohr dead space measured by volumetric capnography

2011 , GRAF SANTOS, JERÓNIMO

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Outcomes of Sepsis and Septic Shock in Cancer Patients: Focus on Lactate

2021 , LOPEZ HERNANDEZ, RENE RAMON , Rodrigo Pérez-Araos , Fernanda Baus , Camila Moscoso , Álvaro Salazar , GRAF SANTOS, JERÓNIMO , José Miguel Montes , Suraj Samtani

The number of oncological patients (OP) admitted to intensive care units (ICU) for sepsis/septic shock has dramatically increased in recent years. The definition of septic shock has been modified, adding hyperlactatemia as a severity biomarker for mortality. However, it remains poorly reported in septic OP. We performed a retrospective analysis from a prospective database of sepsis/septic shock patients admitted to our ICU between September 2017 and September 2019 and followed until day 90. We identified 251 patients and 31.9% had active oncological comorbidity, mainly solid tumor (81.3%). Septic shock criteria were met for 112 (44.6%). Hyperlactatemia was observed in 136 (54.2%) patients and this was associated with a lower survival rate. Overall 90-day mortality was 15.1%. In OP vs. non-OP, hyperlactatemia was more frequent (65% vs. 49.1%, p = 0.013) and associated with lower survival (65.4% vs. 85.7%, p = 0.046). In OP, poor performance status was also associated with lower survival (HR 7.029 [1.998–24.731], p = 0.002) In an adjusted analysis, cancer was associated with lower 90-day survival (HR 2.690 [1.402–5.160], p = 0.003). In conclusion, septic OP remains a high mortality risk group in whom lactate levels and performance status could help with better risk stratification.

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Settings and monitoring of mechanical ventilation during physical therapy in adult critically ill patients: protocol for a scoping review

2019 , GONZALEZ SEGUEL, FELIPE ANDRES , CAMUS MOLINA, AGUSTIN , Anita Jasmén Sepúlveda , PEREZ ARAOS, RODRIGO ALEJANDRO , Jorge Molina Blamey , GRAF SANTOS, JERÓNIMO

IntroductionEarly mobilisation has been extensively advocated to improve functional outcomes in critically ill patients, even though consistent evidence of its benefits has remained elusive. These conflicting results could be explained by a lack of knowledge on the optimal dosage of physical therapy and a mismatch between ventilatory support and exercise-induced patient ventilatory demand. Modern mechanical ventilators provide real-time monitoring of respiratory/metabolic variables and ventilatory setting that could be used for physical therapy dosage or ventilatory support titration, allowing individualised interventions in these patients. The aim of this review is to comprehensively map and summarise current knowledge on adjustments of respiratory support and respiratory or metabolic monitoring during physical therapy in adult critically ill mechanically ventilated patients.Methods and analysisThis is a scoping review protocol based on the methodology of the Joanna-Briggs-Institute. The search strategy will be conducted from inception to 30 June 2019 as a cut-off date in PubMed, CINAHL, Rehabilitation & Sport Medicine, Scielo Citation Index, Epistemónikos, Clinical Trials, PEDro and Cochrane Library, performed by a biomedical librarian and two critical care physiotherapists. All types of articles will be selected, including conference abstracts, clinical practice guidelines and expert recommendations. Bibliometric variables, patient characteristics, physical therapy interventions, ventilator settings and respiratory or metabolic monitoring will be extracted. The identified literature will be analysed by four critical care physiotherapists and reviewed by a senior critical care physician.Ethics and disseminationEthical approval is not required. The knowledge-translation of the results will be carried out based on the End-of-Grant strategies: diffusion, dissemination and application. The results will be published in a peer-review journal, presentations will be disseminated in relevant congresses, and recommendations based on the results will be developed through training for mechanical ventilation and physical therapy stakeholders.

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