Chest
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Do-not-resuscitate (DNR) orders have been espoused for the enhancement of patient autonomy, avoidance of futile medical intervention, and cost containment. Outcomes of cardiopulmonary resuscitation (CPR) in the intensive care setting have been dismal, with few patients surviving to discharge. This study compares patients who died in medical and surgical ICUs in a DNR status with those who died after attempted CPR. ⋯ Among patients dying in the medical and surgical ICUs in the authors' institution, only age and level of consciousness discriminated patients who died in a DNR status from those who died after attempted CPR.
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Comparative Study
Temporal hemodynamic and oxygen transport patterns in medical patients. Septic shock.
Because of the gradual insidious transitions between localized infection, generalized infection, and septic shock, it is difficult to compare data of patients in various stages and to differentiate primary from secondary and tertiary events. The aim of the present study was to describe the sequential pattern of hemodynamic and oxygen transport patterns of survivors and nonsurvivors of septic shock in order to evaluate possible physiologic mechanisms and to provide a template to relate the sequence of physiologic events to biochemical mediators. ⋯ We conclude that increased cardiac index and DO2 represent compensations for circulatory inadequacies that limit body metabolism as reflected by VO2. Cardiac index, DO2, and VO2 values of survivors were higher than those of nonsurvivors and normal values. Therapy directed toward increasing cardiac index to supranormal values empirically determined by survivors has been reported to improve outcome. Additional studies to describe temporal relationships of biochemical mediators of these physiologic patterns are needed.
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A prospective study was done to compare four different methods of securing oral endotracheal tubes: adhesive tape (A), Twill tape (T), Twill tape with FlexBlue bite block (TFXB), and Velcro tie with FlexBlue (VFXB), used on sequential days. Thirty-six patients were enrolled for 136 patient-days and 18 had complete 4-day cycles. The methods were evaluated twice daily by nurses, respiratory therapist, and patient, on a five-point Likert scale with regard to oral hygiene, patient comfort, nurse satisfaction, and ease of use. ⋯ Adhesive tape and T required an oral airway on only 14 days compared with 69 days of FlexBlue use. Extubation on 2 and near extubation occurred on 18 occasions with FlexBlue use and only once with T and accounted for most decisions to change securing method. We cannot recommend the use of the FlexBlue system for securing oral endotracheal tubes.
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Comparative Study
Estimation of ventilatory reserve by stair climbing. A study in patients with chronic airflow obstruction.
Clinicians and surgeons have used the subjective response to the climb of "one or two flights of stairs" to assess the "reserve" of patients with chronic airflow obstruction (CAO). Very little objective data exist regarding the metabolic and ventilatory cost for any level of stair climbing in these patients. Therefore, this study was designed to evaluate the use of symptom-limited stair climbing as a simple method to estimate the peak oxygen uptake (VO2) and minute ventilation (VE) in patients with CAO. ⋯ We conclude that a symptom-limited maximal stair climb helps estimate peak VO2 and VE in patients with CAO. The frequently advocated test to climb one to two flights to evaluate cardiopulmonary reserve is not adequate for most patients with CAO. Symptom-limited maximal stair climbing is a simple, inexpensive and readily available test that may be used to evaluate the cardiopulmonary reserve of stable patients with CAO.
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Case Reports
Massive macroglossia as a presenting feature of hypothyroid-associated pericardial effusion.
An 81-year-old woman presented with massive macroglossia and signs of both hypothyroidism and pericardial tamponade. Drainage of the pericardial effusion produced dramatic resolution of the macroglossia. Marked elevation of central venous pressure may result in macroglossia, possibly because of anomalous venous drainage of the tongue.