Critical care medicine
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Although the Kistner tracheostomy tube was introduced 20 years ago, it has never been formally evaluated. This tube is an appliance used to maintain a tracheostomy stoma when there is some doubt as to the patient's ability to maintain his airway without a tracheostomy tube. The Kistner tube is a short tube that occupies only the distance from the skin to the inside of the tracheal wall. ⋯ Proper placement of the tube is of outstanding importance ot prevent protrusion of the tube into the tracheal lumen causing obstruction of the airway. Recommended maneuvers for prevention of complications along with advantages and shortcomings of the tube are discussed. With proper selection of the patient, use of the Kistner tracheostomy tube provides a safe and effective method to remove retained secretions and to wean from tracheostomy.
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Critical care medicine · Jan 1980
Alternatives to total parenteral nutrition in the critically ill patient.
Alternatives to total parenteral nutrition (TPN) can play an invaluable role in the support of the critically ill patient. However, the efficacy of this depends on: (1) early nutritional assessment; (2) sequential nutritional assessment as dictated by the clinical condition of the patient; (3) careful estimation of requirements based on calculated energy expenditure and use of the "stress-index"; (4) early use of enteral feedings in combination with peripheral and central intravenous routes, especially with the use of "feeding modules" to provide patient's specific concentrated diet; (5) use of intravenous fat as an isotonic supplement to dextrose in the presence of carbohydrate intolerance; (6) avoid overfeeding as rigorously as underfeeding; (7) continued clinical trials to determine optimal nutritional/metabolic support of the critically ill.
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Critical care medicine · Dec 1979
Case ReportsUse of positive airway pressure without endotracheal intubation.
Continuous positive airway pressure (CPAP) and expiratory positive airway pressure (E-PAP) may be used safely without endotracheal intubation in patients with acute respiratory failure when strict selection criteria are adhered to. The therapy should be titrated to reduce intrapulmonary shunting, improve PaO2, and reduce FIO2. Other considerations include balancing oxygen consumption against cardiac output and oxygen transport. Absolute or relative indications for abandoning the technique and using endotracheal intubation with mechanical ventilatory support include unrelenting hypoxia, patient exhaustion, rising PaCO2, development of metabolic acidosis, presence of ventricular arrhythmias, and inability to protect the airway.
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Critical care medicine · Dec 1979
Pneumothorax and pneumomediastinum during pediatric mechanical ventilation.
The incidence of pulmonary barotrauma during mechanical ventilation in children beyond the neonatal age group was studied in two groups of patients. In the first group, 179 cases of pediatric mechanical ventilation for over 12 hours were retrospectively analyzed for the occurrence of pneumothorax and pneumomediastrinum. Eleven percent (6 of 57) of young infants (0--6 months) without hyaline membrane disease and 3% (4 of 122) of older infants and children (over 6 months) developed these complications. ⋯ Overall, 64% (9 of 14) of this group developed pulmonary barotrauma and 43% (6 of 14) developed pneumothorax. Of 9 patients receiving PEEP greater than or equal to 15 cm H2O for longer than 24 hours, 6 developed pulmonary barotrauma after the first 24 hours. The incidence of pneumothorax and pneumomediastinum in ventilated infants without hyaline membrane disease and children is comparable to adult series.
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Critical care medicine · Dec 1979
Influence of an end inspiratory pause on pulmonary ventilation, gas distribution, and lung perfusion during artificial ventilation.
Using a constant tidal volume and ventilatory frequency, anesthetized piglets were ventilated with a new tidal volume ventilator. A short inspiratory time without a pause (10% of breathing cycle) was compared with a longer inspiratory time with a pause (33%) both with and without bronchial obstruction. Mechanics of ventilation, pulmonary ventilation, gas exchange, gas distribution, and lung perfusion were measured. ⋯ While the cranial pulmonary fields were less well ventilated, the right caudal field was better ventilated. In the presence of bronchial obstruction, better alveolar ventilation was achieved when an end inspiratory pause was added. The results emphasize the importance of static end inspiratory tracheal conditions although the tidal volumes were kept unchanged.