Masui. The Japanese journal of anesthesiology
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The clinical criteria of acute respiratory distress syndrome (ARDS) defined by the American-European Consensus Conference (AECC) in 1994 was relevant to clinical practice, trials, and researches for two decades. However, a number of issues with the AECC definition have become apparent. ⋯ In the second section, the clinical significance and limitation of radiographic imaging, especially, high-resolution CT (HRCT) findings in ARDS were addressed. Although the early exudative phase of ARDS can not be detected even by HRCT, pulmonary fibroproliferation assessed by HRCT in patients with early ARDS predicts increased mortality with an increased susceptibility to multiple organ failure, along with ventilator dependency and its associated outcomes.
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Randomized Controlled Trial
[Continuous infusion of low-dose remifentanil for palliation of pain with epidural catheterization].
To prospectively determine the safety and effectiveness of continuous infusion of low-dose remifentanil for the reduction of pain in patients for epidural catheterization. ⋯ Continuous infusion of low-dose remifentanil is a safe and effective method for palliation of pain in epidural catheterization.
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We have patients who develop lung injury after surgery even they are without lung diseases preoperatively. What is the cause of this perioperative complication? Can we prevent postoperative lung injury by any measures during surgery? In the present paper, the etiology of acute respiratory distress syndrome (ARDS) is reviewed and possible methods to prevent ARDS is discussed. Inflammation occurs during surgery, the degree of which depends on multiple factors including surgical insults, the use of cardiopulmonary bypass (CPB), ischemia and reperfusion of any organ during surgery, transfusion, and organ damages. ⋯ Mechanical ventilation does not initiate lung injury by itself; however, conventional mechanical ventilation (tidal volume of 10-12 ml x kg-1 ideal body weight) may induce ARDS if lungs are primed. Accordingly, lung protective strategies should be carried out if patients have such condition or does receive such surgery. The brief outline of the lung protective strategies is to reduce tidal volume, to apply open lung approach with positive end-expiratory pressure and lung recruitment maneuver, and to avoid any lung lesion causing hypoxia during CPB or one-lung ventilation.
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Bacterial and viral pneumonia are the most frequent causes of ARDS. The other infectious risk of developing of ARDS is infections at nonpulmonary sites, and fungal as well as parasites pneumonia. Virtually all patients with ARDS require mechanical ventilation, a major risk factor for the development of VAP.
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In this article lung protective strategy using low tidal volume and low plateau pressure is discussed based on the Acute Respiratory Distress Syndrome Network protocol. The ARDS Network study, which reported a lower mortality with a tidal volume target 6 ml x kg-1 of predicted body weight, remains the only study to show that mechanical ventilation strategy improves outcome in patients with acute lung injury/acute respiratory distress syndrome. To liberate patients from mechanical ventilation in timely manner, daily assessment with spontaneous breathing trial is essential. Using weaning predictors or gradual withdrawal with SIMV mode prolongs the duration of weaning, and is not recommended.