Intensive care medicine
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Intensive care medicine · Jan 1984
The role of total static lung compliance in the management of severe ARDS unresponsive to conventional treatment.
A group of 36 patients with severe adult respiratory distress syndrome (ARDS) meeting previously established blood gas criteria (mortality rate 90%) became candidates for possible extracorporeal respiratory support [low frequency positive pressure ventilation with extracorporeal CO2 removal (LFPPV-ECCO2R)]. Before connecting the patients to bypass we first switched the patients from conventional mechanical ventilation with positive end expiratory pressure (PEEP) to pressure controlled inverted ratio ventilation (PC-IRV), and then when feasible, to spontaneous breathing with continuous positive airways pressure (CPAP). Forty eight hours after the patients had entered the treatment protocol, only 19 out of the 36 patients in fact required LFPPV-ECCO2R, while 5 were still on PC-IRV, and 12 were on CPAP. ⋯ No patients with a TSLC lower than 25 ml (cm H2O)-1 tolerated either PC-IRV or CPAP, while all patients with a TSLC higher than 30 ml (cm H2O)-1 were successfully treated with CPAP. Borderline patients (TSLC between 25 and 30 ml (cm H2O)-1) had to be treated with PC-IRV for more than 48 h, or were then placed on LFPPV-ECCO2R if Paco2 rose prohibitively. We conclude that TSLC is a most useful measurement in deciding on the best management of patients with severe ARDS, unresponsive to conventional treatment.
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Six patients with acute respiratory failure were treated with high-frequency jet ventilation (HFJV): 3 because they developed barotrauma while on conventional mechanical ventilation (CMV), 2 because of sedative- or PEEP-induced hypotension on CMV, and 1 because of bronchopleural fistula. In all patients, except the one with bronchopleural fistula, who was treated from the start with HFJV, gas exchange before (while on CMV) and after institution of HFJV could be compared. In these five patients, including the two with acute respiratory failure not complicated by barotrauma, gas exchange was better during HFJV than during CMV for the same levels of FIO2 and PEEP. HFJV therefore seems the method of choice for ventilatory support, not only in patients with bronchopulmonary disruption, but also in patients with hemodynamic embarrassment during CMV.
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Circulatory failure occurs in about 10% of patients with pulmonary embolism, resulting from a massive obstruction of the pulmonary arterial bed. Hemodynamic and respiratory features are well established; they involve precapillary pulmonary hypertension, low cardiac output state, elevated filling pressure for the right ventricle, and venous admixture. More recently, two-dimensional echocardiography permitted the visualization of pulmonary artery and right heart enlargement, reduced right ventricular ejection fraction, and tricuspid regurgitation. Evaluated by this latter means, left ventricular systolic function appeared unchanged, but diastolic function might be reduced by septal bulging.
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Intensive care medicine · Jan 1984
Blood coagulation and fibrinolytic factors and their inhibitors in critically ill patients.
In a search for new variables, for the diagnosis of disseminated intravascular coagulation (DIC) and for guidelines of therapy in such conditions, 22 severely ill patients were studied. The diagnosis of DIC was based on determinations of platelet counts, prothrombin complex (Normotest), antithrombin (AT), fibrinogen degradation products and fibrinogen. Nine patients were diagnosed as having DIC, eight patients were referred to a suspected DIC group and five to a group of no DIC. ⋯ The inhibitor capacity (AT, APV and KI) was lower in patients who died than in survivors and decreased still further in those of the non-survivors who had DIC. Thus the inhibitors can be used as predictors of outcome and hopefully for guiding therapy. To establish the diagnosis of DIC we suggest measurement of platelet count, prothrombin complex, plasminogen as well as of the inhibitors.
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Intensive care medicine · Jan 1984
Case ReportsUnilateral high frequency jet ventilation. Reduction of leak in bronchopleural fistula.
A young alcoholic presented with severe bilateral bronchopneumonia, which required prolonged treatment with intermittent positive pressure ventilation. High airway pressures were necessary for effective gas exchange. A recurrent tension pneumothorax led to a persistent bronchopleural fistula which resulted in hypercarbia and hypoxaemia despite the use of large minute volumes. ⋯ Asynchronous independent lung ventilation was instituted, using a double-lumen endobronchial tube. A considerable leak still occurred through the bronchopleural fistula, and it was only when high frequency jet ventilation was substituted to the fistula-containing lung that the leak was virtually abolished, while improving gas exchange. High frequency jet ventilation in bronchopleural fistula is of potential benefit.