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Transfusion-Related Acute Lung Injury (TRALI) is a relatively unusual, life-threatening clinical syndrome, characterized by acute respiratory failure, hyp otension, and non-cardiogenic pulmonary edema during or within 6 hours after a blood product transfusion. Although its true incidence is unknown, it has been attributed one case per 5.000 transfusions of any blood product and has been one of the most frequent causes of transfusion -related death. We present a case of TRALI in the perioperative period of cardiac surgery with extreme clinical manifestations, whose therapeutic approach was extremely difficult for the medical -surgical team, due to its complex clinical setting: cardiac surgery with cardiopulmonary bypass due to diagnosis of infective endocarditis, previous lung injury and history of other post-transfusion reaction., La lesión pulmonar aguda producida por transfusión ( TRALI, por sus siglas en inglés) es un síndrome clínico relativamente raro, que puede constituir una am e- naza para la vida y que se caracteriza por insuficiencia respiratoria aguda, edema pulmonar no cardiogénico e hipotensión arterial durante o en el transcurso de 6 horas después de una transfusión de productos hemáticos. Aunque su verdadera incidencia es desconocida, se le ha atribuido 1 caso por cada 5000 transfusiones de cualquier producto hemático y ha sido una de las causas más frecuentes de muerte relacionada con la transfusión. Se presenta un caso de TRALI en el perioperatorio de una cirugía cardíaca con manifestaciones clínicas extremas, cuyo abordaje terapéutico fue extremadamente difícil para el equipo médico-quirúrgico, debido al contexto clínico en el que se presentó: cirugía cardíaca con circulación extracorpórea por diagnóstico de endocarditis infecciosa, lesión pulmonar previa y antecedente de otro tipo de reacción postransfusional.

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12-16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.© Copyright © 2021 Team, Team, Jones, Teede and Weller.

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12-16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.© Copyright © 2021 Team, Team, Jones, Teede and Weller.

Early use of neuromuscular blockers agents (NMBAs) in moderate-severe adult respiratory distress syndrome (ARDS) has previously been associated with a mortality decrease in the ACURASYS trial in 2010. However, the recently published ROSE study (Reevaluation of Systemic Early Neuromuscular Blockade) points out the disagreement with this practice., El uso precoz de bloqueantes neuromusculares (BNM) en el síndrome de distrés respiratorio del adulto (SDRA) moderado-severo se había asociado a una disminución de la mortalidad en el ensayo ACURASYS en 2010. El recientemente publicado estudio ROSE (Reevaluation of Systemic Early Neuromuscular Blockade) pone en evidencia esta práctica.

In this retrospective observational study performed in a high-volume hepatobiliary-pancreatic unit, we evaluated the effect of a surgery-specific goal-directed therapy (GDT) physiologic algorithm on complications and length of hospital stay. We compared patients who underwent pancreaticoduodenectomy with either a standardised Enhanced Recovery After Surgery program (usual care group), or a standardised Enhanced Recovery After Surgery program in combination with a surgery-specific cardiac output-guided algorithm (GDT group). We included 145 consecutive patients: 47 in the GDT group and 98 in the usual care group. Multivariable associations between GDT and lengths of stay and complications were investigated using negative binomial regression. Postoperative complications were common and occurred at similar frequencies amongst the GDT and usual care groups: 64% versus 68% respectively, P=0.71; odds ratio 0.82; (95% confidence interval 0.39-1.70). There were fewer cardiorespiratory complications in the GDT group. Median (interquartile range) length of hospital stay was ten days (8.0-14.0) in the GDT group compared to 13 days (8.8-21.3) in the usual care group, P=0.01. Median (interquartile range) total intraoperative fluid was 3,000 ml (2,050-4,175) in the GDT group compared to 4,500 ml (3,275-5,325) in the usual care group, P <0.0001; but by day one, the median (interquartile range) fluid balance was similar (1,198 ml [700-1,729] in the GDT group versus 977 ml [419-2,044] in the usual care group, P=0.96). Use of vasoactive medications was higher in the GDT group. In our patients undergoing pancreaticoduodenectomy, GDT was associated with restrictive intraoperative fluid intervention, fewer cardiorespiratory complications and a shorter hospital length of stay compared to usual care. However, we could not exclude an influence of surgical caseload, which we have previously found to be an important variable. We also could not relate the increased hospital length of stay to

The adoption of point-of-care lung ultrasound for both suspected and confirmed COVID-19 patients highlights the issues of accessibility to ultrasound training and equipment. Lung ultrasound is more sensitive than chest radiography in detecting viral pneumonitis and preferred over computed tomography for reasons including its portability, reduced healthcare worker exposure and repeatability. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular pleural line and subpleural consolidations. Consolidations are most likely found in critical patients in need of ventilatory support. Hence, lung ultrasound may be used to timely triage patients who may have evolving pneumonitis. Other respiratory pathology that may be detected by lung ultrasound includes pulmonary oedema, pneumothorax, consolidation and large effusion. A key barrier to incorporate lung ultrasound in the assessment of COVID-19 patients is adequate decontamination of ultrasound equipment to avoid viral spread. This tutorial provides a practical method to learn lung ultrasound and a cost-effective method of preventing contamination of ultrasound equipment and a practical method for performing and interpreting lung ultrasound.Copyright © 2020 Australasian Society for Ultrasound in Medicine

In this retrospective observational study performed in a high-volume hepatobiliary-pancreatic unit, we evaluated the effect of a surgery-specific goal-directed therapy (GDT) physiologic algorithm on complications and length of hospital stay. We compared patients who underwent pancreaticoduodenectomy with either a standardised Enhanced Recovery After Surgery program (usual care group), or a standardised Enhanced Recovery After Surgery program in combination with a surgery-specific cardiac output-guided algorithm (GDT group). We included 145 consecutive patients: 47 in the GDT group and 98 in the usual care group. Multivariable associations between GDT and lengths of stay and complications were investigated using negative binomial regression. Postoperative complications were common and occurred at similar frequencies amongst the GDT and usual care groups: 64% versus 68% respectively, P=0.71; odds ratio 0.82; (95% confidence interval 0.39-1.70). There were fewer cardiorespiratory complications in the GDT group. Median (interquartile range) length of hospital stay was ten days (8.0-14.0) in the GDT group compared to 13 days (8.8-21.3) in the usual care group, P=0.01. Median (interquartile range) total intraoperative fluid was 3,000 ml (2,050-4,175) in the GDT group compared to 4,500 ml (3,275-5,325) in the usual care group, P <0.0001; but by day one, the median (interquartile range) fluid balance was similar (1,198 ml [700-1,729] in the GDT group versus 977 ml [419-2,044] in the usual care group, P=0.96). Use of vasoactive medications was higher in the GDT group. In our patients undergoing pancreaticoduodenectomy, GDT was associated with restrictive intraoperative fluid intervention, fewer cardiorespiratory complications and a shorter hospital length of stay compared to usual care. However, we could not exclude an influence of surgical caseload, which we have previously found to be an important variable. We also could not relate the increased hospital length of stay to

The adoption of point-of-care lung ultrasound for both suspected and confirmed COVID-19 patients highlights the issues of accessibility to ultrasound training and equipment. Lung ultrasound is more sensitive than chest radiography in detecting viral pneumonitis and preferred over computed tomography for reasons including its portability, reduced healthcare worker exposure and repeatability. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular pleural line and subpleural consolidations. Consolidations are most likely found in critical patients in need of ventilatory support. Hence, lung ultrasound may be used to timely triage patients who may have evolving pneumonitis. Other respiratory pathology that may be detected by lung ultrasound includes pulmonary oedema, pneumothorax, consolidation and large effusion. A key barrier to incorporate lung ultrasound in the assessment of COVID-19 patients is adequate decontamination of ultrasound equipment to avoid viral spread. This tutorial provides a practical method to learn lung ultrasound and a cost-effective method of preventing contamination of ultrasound equipment and a practical method for performing and interpreting lung ultrasound.Copyright © 2020 Australasian Society for Ultrasound in Medicine

BACKGROUND: Prone position (PP) improves acute respiratory distress syndrome (ARDS) survival by reducing the risk of ventilation-induced lung injury. However, inter-individual variability is a hallmark of ARDS and lung protection by PP might not be optimal in all patients. In the present study, we dynamically assessed physiologic effects of PP by electrical impedance tomography (EIT) and identified predictors of improved lung protection by PP in ARDS patients. METHODS: Prospective physiologic study on 16 intubated, sedated and paralyzed patients with ARDS undergoing PP as per clinical decision. EIT data were recorded during two consecutive steps: 1) baseline supine position before and after a recruitment maneuver (RM); 2) prone position before and after a RM. “Improved lung protection” by PP was defined in the presence of simultaneous improvement of ventilation homogeneity (Hom), alveolar overdistension and collapse (ODCL) and amount of recruitable lung volume by RM in comparison to supine. RESULTS: PP versus supine increased the tidal volume distending the dependent regions (Vtdep), resulting in improved Hom (1.1±0.9 vs. 1.7±0.9, P=0.021). PP also reduced ODCL (19±9% vs. 28±8%, P=0.005) and increased the recruitable lung volume (80 [71-157] vs. 59 [1-110] mL, P=0.025). “Improved lung protection” by PP was predicted by lower Vtdep, higher Vtndep and poorer Hom measured during baseline supine position (P<0.05). CONCLUSIONS: EIT enables dynamic bedside assessment of the physiologic effects of PP and might support early recognition of ARDS patients more likely to benefit from PP.

El SDRA es una enfermedad cuya incidencia ha cambiado a través de los años y la predicción de desenlaces representa uno de los mayores retos en la actualidad. A nivel mundial se conocen pocas publicaciones acerca del comportamiento de puntajes como el APPS y el índice de oxigenación ajustado y su valor predictivo con respecto a desenlaces como mortalidad. Objetivo: Describir la severidad del compromiso por SDRA según el índice de oxigenación ajustado y el puntaje APPS en los pacientes adultos hospitalizados en la Unidad de Cuidado Intensivo del Hospital Universitario Fundación Santa Fe de Bogotá del 01 de Enero de 2009 hasta el 31 de Diciembre de 2018. Resultados: Se recolectó información de 18 pacientes con una mediana de estancia en UCI de 14 días. La edad promedio fue 64.55 años y el 55.56% fueron hombres. El puntaje de SOFA promedio fue de 9.94 puntos y el puntaje APACHE II promedio de 23.44 puntos. Más del 60% de los pacientes tenían comprometidos entre 2 y 3 órganos, 61% requirió dentro de su manejo relajante neuromuscular, sólo en 2 pacientes se usó circulación extracorpórea y en 27% de los pacientes se indicó el manejo con ventilación en posición prona. El promedio del índice de oxigenación ajustado fue 90.45 y el promedio del puntaje APPS fue 5.94. Conclusiones: Los puntajes de severidad APPS e índice de oxigenación ajustado son aproximaciones valiosas para predecir la mortalidad a mediano plazo lo cual permitirá optimizar los recursos disponibles racionalizando el uso de estrategias ventilatorias y no ventilatorias alternativas., Introduction: ARDS is a disease witch incidence has changed over the year, the prediction of outcomes represents one of the greatest challenges in the present. Worldwide, few publications are known about the behavior of scores such as the APPS and the adjusted oxygenation index and its predictive value for outcomes such as mortality. Objective: Describe the severity of the ARDS compromise according to the index of adjusted oxygenation and the APPS score in adult patients hospitalized in the Intensive Care Unit of the Hospital universitario Fundación Santa Fe de Bogotá from January 01, 2009 to December 31, 2018. Results: Information was collected from 18 patients with a median stay in the ICU of 14 days. The average age was 64.55 years and 55.56% were men. The average SOFA score was 9.94 points and the average APACHE II score was 23.44 points. More than 60% of the patients had 2 to 3 organs compromised, 61% required neuromuscular blocki, only 2 patients had extracorporeal circulation and in 27% of the patients ventilation in the prone position was indicated. The adjusted oxygenation index average was 90.45 and the average APPS score was 5.94. Conclusions: APPS severity scores and adjusted oxygenation index are valuable approaches for predicting mortality in the medium term, which will optimize available resources by rationalizing the use of alternative ventilatory and non-ventilatory strategies., Correo 11 jun 2019. mi nombre es Claudia Marcela Ramirez residente de medicina critica y cuidado intensivo de la Universidad del rosario, el día de hoy tras la autorizacion por parte de la oficina de posgrados subí mi tesis en modo PDF Descripción del índice de oxigenación ajustado y del puntaje APPS en los pacientes adultos con SDRA de la Unidad de Cuidado Intensivo del Hospital Universitario Fundación Santa Fe de Bogotá según lo requerido por la universidad, sin embargo dicho articulo esta en proceso de ser publicado por la sociedad neurológica de Colombia y sera presentado en forma de poster en a asoneumocito, por lo que pido bloqueo de la publicación por 6 meses, agradezco inmensamente su colaboración Rta. 16 jul 2019. Respetada Claudia, reciba un cordial saludo Se ha realizado la publicación de su documento, el cual puede consultar en el siguiente enlace: http://repository.urosario.edu.co/handle/10336/19946 De acuerdo con su solicitud, el documento ha quedado embargado hasta el 16 de enero de 2020. Si usted desea dejarlo con acceso abierto antes de finalizar dicho periodo o si por el contrario desea extender el embargo, puede enviar un correo a esta misma dirección realizando la solicitud. Tenga en cuenta que los documentos en acceso abierto propician una mayor visibilidad de su producción académica y científica. Quedo atenta a cualquier inquietud o sugerencia.

Editor's Perspective What We Already Know about This Topic Hospital mortality in acute respiratory distress syndrome is approximately 40%, but mortality and trajectory in "mild" acute respiratory distress syndrome (classified only since 2012) are unknown, and many cases are not detected What This Article Tells Us That Is New Approximately 80% of cases of mild acute respiratory distress syndrome persist or worsen in the first week; in all cases, the mortality is substantial (30%) and is higher (37%) in those in whom the acute respiratory distress syndrome progresses Background: Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. Methods: This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: "worsening" if moderate or severe acute respiratory distress syndrome criteria were met, "persisting" if mild acute respiratory distress syndrome criteria were the most severe category, and "improving" if patients did not fulfill acute respiratory distress syndrome criteria any more from day 2. Results: Among 580 patients with initial mild acute respiratory distress syndrome, 18% (103 of 580) continuously improved, 36% (210 of 580) had persisting mild acute respiratory distress syndrome, and 46% (267 of 580) worsened in the first week after acute respiratory distress syndrome onset. Global in

METHODS: We performed a multicentre, prospective, observational study. We collected clinical, ventilatory and arterial blood gas data twice daily for 7 days. We performed subgroup analysis by sex and assessment of arterial partial pressure of carbon dioxide (PaCO2) management where hypercapnia was potentially physiologically contraindicated. RESULTS: We recorded 453 observational sets in 123 patients across seven ICUs. The most commonly selected initial VT was 500 mL (33%), and this proportion did not differ according to sex (32% male, 34% female). Moreover, 38% of patients were exposed to initial VT per predicted body weight (VT-PBW) > 8.0 mL/kg. VT-PBW in this range were more likely to occur in females, those with a lower height, lower ideal body weight or in those for whom hypercapnia was potentially physiologically contraindicated. As a consequence, females were more frequently exposed to a lower PaCO2 and higher pH. CONCLUSIONS: In adults without ARDS undergoing CMV in Australian ICUs, the initial VT was a stereotypical 500 mL in one-third of participants, irrespective of sex. Moreover, around 40% of patients were exposed to an initial VT-PBW > 8.0 mL/kg. Finally, women were more likely to be exposed to a high VT and hyperventilation. BACKGROUND: The setting of tidal volume (VT) during controlled mechanical ventilation (CMV) in critically ill patients without acute respiratory distress syndrome (ARDS) is likely important but currently unknown. We aimed to describe current CMV settings in intensive care units (ICUs) across Victoria.

METHODS: We performed a multicentre, prospective, observational study. We collected clinical, ventilatory and arterial blood gas data twice daily for 7 days. We performed subgroup analysis by sex and assessment of arterial partial pressure of carbon dioxide (PaCO2) management where hypercapnia was potentially physiologically contraindicated. RESULTS: We recorded 453 observational sets in 123 patients across seven ICUs. The most commonly selected initial VT was 500 mL (33%), and this proportion did not differ according to sex (32% male, 34% female). Moreover, 38% of patients were exposed to initial VT per predicted body weight (VT-PBW) > 8.0 mL/kg. VT-PBW in this range were more likely to occur in females, those with a lower height, lower ideal body weight or in those for whom hypercapnia was potentially physiologically contraindicated. As a consequence, females were more frequently exposed to a lower PaCO2 and higher pH. CONCLUSIONS: In adults without ARDS undergoing CMV in Australian ICUs, the initial VT was a stereotypical 500 mL in one-third of participants, irrespective of sex. Moreover, around 40% of patients were exposed to an initial VT-PBW > 8.0 mL/kg. Finally, women were more likely to be exposed to a high VT and hyperventilation. BACKGROUND: The setting of tidal volume (VT) during controlled mechanical ventilation (CMV) in critically ill patients without acute respiratory distress syndrome (ARDS) is likely important but currently unknown. We aimed to describe current CMV settings in intensive care units (ICUs) across Victoria.

Experimental and clinical observational studies have shown potential benefits of statin administration in the acute respiratory distress syndrome (ARDS) by modulating inflammation and preventing worsening respiratory function. More recently, two randomized clinical trials failed to demonstrate an improved survival of ARDS patients treated with statins. In the first study, conducted by the ARDS Network, 745 patients with sepsis associated ARDS were randomized within 48-hours of onset to receive either rosuvastatin or placebo. There was no significant difference between the rosuvastatin and placebo groups for hospital mortality (primary outcome, 29% vs. 25%, P=0.21) or ventilator free days (15±11 vs. 15±11, respectively; P=0.96). In rosuvastatin treated patients, renal and hepatic failure free days were significantly lower than in the placebo group, raising serious safety concerns. In the second study (HARP-2 trial), 540 patients with ARDS were randomized within 48-hours of onset to receive either simvastatin (80 mg/day) or placebo. There was no significant difference between the study groups for number of ventilator free days (primary outcome, 13±10 in the simvastatin vs. 12±10 in the placebo group, P=0.21) or 28-day mortality (22% vs. 27%, respectively; P=0.23). No significant difference in serious adverse events was reported between groups. Herein, we discuss the main reasons for these negative findings and consider where there could be a role for statins in ARDS patients., SCOPUS: ar.j, info:eu-repo/semantics/published

Background Aspiration-induced lung injury can decrease gas exchange and increase mortality. Acute lung injury following acid aspiration is characterized by elevated pulmonary blood flow (PBF) in damaged lung areas in the early inflammation stage. Knowledge of PBF patterns after acid aspiration is important for targeting intravenous treatments. We examined PBF in an experimental model at a later stage (2 hours after injury). Methods Anesthetized Wistar-Unilever rats (n = 5) underwent unilateral endobronchial instillation of hydrochloric acid. The PBF distribution was compared between injured and uninjured sides and with that of untreated control animals (n = 6). Changes in lung density after injury were measured using computed tomography (CT). Regional PBF distribution was determined quantitatively in vivo 2 hours after acid instillation by measuring the concentration of [68Ga]-radiolabeled microspheres using positron emission tomography. Results CT scans revealed increased lung density in areas of acid aspiration. Lung injury was accompanied by impaired gas exchange. Acid aspiration decreased the arterial pressure of oxygen from 157 mmHg [139;165] to 74 mmHg [67;86] at 20 minutes and tended toward restoration to 109 mmHg [69;114] at 110 minutes (P < 0.001). The PBF ratio of the middle region of the injured versus uninjured lungs of the aspiration group (0.86 [0.7;0.9], median [25%;75%]) was significantly lower than the PBF ratio in the left versus right lung of the control group (1.02 [1.0;1.05]; P = 0.016). Conclusions The PBF pattern 2 hours after aspiration-induced lung injury showed a redistribution of PBF away from injured regions that was likely responsible for the partial recovery from hypoxemia over time. Treatments given intravenously 2 hours after acid-induced lung injury may not preferentially reach the injured lung regions, contrary to what occurs during the first hour of inflammation.

ObjectivesIn the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols.DesignRetrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock.SettingICUs of Acute Respiratory Distress Syndrome Network participating hospitals.PatientsFive hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite.InterventionsFluid management by protocol.Measurements and main resultsCumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, -136 ± 491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ± 0.3) were equivalent to FACTT Conservative (14.6 ± 0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ± 0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite).ConclusionsFACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite

Introduction: Our aim was to provide descriptive information to burn clinicians, who have extensive experience treating major burns and determining prognosis, as to whether significant differences in mortality exist between major burns injuries and the comparatively less common toxic epidermal necrolysis for a given age and total body surface area percentage. Method(s): Retrospective data was analyzed of all deceased patients admitted to the Victorian Adult Burns Service in Melbourne, Australia over a period of 10 years with greater than 30% total body surface area burned or greater than 30% total body surface area epidermal detachment in the case of toxic epidermal necrolysis. Retrospective data was also collected on all patients, survivors and deceased, with toxic epidermal necrolysis and these patients were matched with burns patients by age and % total body surface area burned. Comparisons in outcomes were performed with mortality being the primary variable of interest. Result(s): Toxic epidermal necrolysis patients that died were older (median: 68.5 vs 57 yrs; P = 0.04), had a longer length of hospital stay (36.5 vs 0.8 days; P = 0.001) and significantly longer periods of mechanical ventilation (1404 vs 14.5 h; P = 0.011) than major burns patients that died. When toxic epidermal necrolysis patients were matched to major burns patients by age and total body surface area burned, there were no significant differences between the two groups with respect to mortality. Conclusion(s): Palliative care approaches are more frequently administered at the time of presentation for major burns patients in comparison to toxic epidermal necrolysis patients. This may be due to a perception that if toxic epidermal necrolysis patients can survive their initial systemic injury, they are likely to survive, as opposed to major burns patients who often undergo extensive surgery and for whom other factors should be taken into account in the context of end-of-life decision making.Copyr

The use of extracorporeal membrane oxygenation (ECMO)for severe acute respiratory failure (ARF) in adults is growing rapidly given recent advances in technology, even though there is controversy regarding the evidence justifying its use. Because ECMOis a complex, high-risk, and costly modality, at present it should be conducted in centers with sufficient experience, volume, and expertise to ensure it is used safely. This position paper represents the consensus opinion of an international group of physicians and associated health-care workers who have expertise in therapeutic modalities used in the treatment of patients with severe ARF, with a focus on ECMO. The aim of this paper is to provide physicians,ECMOcenter directors and coordinators, hospital directors, health-care organizations, and regional, national, and international policy makers a description of the optimal approach to organizing ECMO programs for ARF in adult patients. Importantly, this will help ensure that ECMO is delivered safely and proficiently, such that future observational and randomized clinical trials assessing this technique may be performed by experienced centers under homogeneous and optimal conditions. Given the need for further evidence, we encourage restraint in the widespread use of ECMO until we have a better appreciation for both the potential clinical applications and the optimal techniques for performing ECMO.Copyright © 2014 by the American Thoracic Society.

Rationale: The H1N1 influenza pandemic of 2009 was a global disaster and the intensive care unit (ICU) course was characterised by prolonged mechanical ventilation and length of stay (LOS). Previous research conducted in people with acute respiratory distress syndrome has demonstrated impairments in physical function and health-related quality of life (HR-QoL) which persist up to five years following ICU admission. Previous Australian data demonstrate that general ICU survivors return to pre-existing HR-QoL however it is unclear whether HR-QoL is disproportionately affected in patients with H1N1 influenza. The hypothesis was that mechanically ventilated Australasian adult survivors of H1N1 influenza would have worse HR-QoL than the healthy population one year following ICU discharge. Method(s): A prospective observational cohort study was conducted with institutional review board approval. Eligible participants were admitted to ICU and mechanically ventilated with a confirmed diagnosis of H1N1 influenza from eleven ICUs in Australia and New Zealand during the period June-September, 2009. People were excluded if aged < 18 years or they could not speak English. Eligible participants were contacted by letter and informed consent sought via a scripted telephone call. Demographic details were extracted from the Australian and New Zealand Intensive Care Influenza Investigators registry (INFINITE) and local intensive care databases. Two HR-QoL questionnaires validated in the ICU population were administered one year following ICU: Short Form-36 Version 2 (SF-36) and the Assessment of Quality of Life (AQoL). Result(s): Sixty-two people were recruited (48% male). The median (IQR) age was 42 (29 to 53) years, APACHE II score was 18.0 (14 to 20); ventilation days were 10.0 (4 to 23); ICU and hospital LOS was 12.5 (7 - 27) and 20.0 (15 - 38) days respectively. Hospital mortality was 7% and 31% of the cohort received a tracheostomy. The mean (SD) health utility score at one year

Introduction: Our aim was to provide descriptive information to burn clinicians, who have extensive experience treating major burns and determining prognosis, as to whether significant differences in mortality exist between major burns injuries and the comparatively less common toxic epidermal necrolysis for a given age and total body surface area percentage. Method(s): Retrospective data was analyzed of all deceased patients admitted to the Victorian Adult Burns Service in Melbourne, Australia over a period of 10 years with greater than 30% total body surface area burned or greater than 30% total body surface area epidermal detachment in the case of toxic epidermal necrolysis. Retrospective data was also collected on all patients, survivors and deceased, with toxic epidermal necrolysis and these patients were matched with burns patients by age and % total body surface area burned. Comparisons in outcomes were performed with mortality being the primary variable of interest. Result(s): Toxic epidermal necrolysis patients that died were older (median: 68.5 vs 57 yrs; P = 0.04), had a longer length of hospital stay (36.5 vs 0.8 days; P = 0.001) and significantly longer periods of mechanical ventilation (1404 vs 14.5 h; P = 0.011) than major burns patients that died. When toxic epidermal necrolysis patients were matched to major burns patients by age and total body surface area burned, there were no significant differences between the two groups with respect to mortality. Conclusion(s): Palliative care approaches are more frequently administered at the time of presentation for major burns patients in comparison to toxic epidermal necrolysis patients. This may be due to a perception that if toxic epidermal necrolysis patients can survive their initial systemic injury, they are likely to survive, as opposed to major burns patients who often undergo extensive surgery and for whom other factors should be taken into account in the context of end-of-life decision making.Copyr

Rationale: The H1N1 influenza pandemic of 2009 was a global disaster and the intensive care unit (ICU) course was characterised by prolonged mechanical ventilation and length of stay (LOS). Previous research conducted in people with acute respiratory distress syndrome has demonstrated impairments in physical function and health-related quality of life (HR-QoL) which persist up to five years following ICU admission. Previous Australian data demonstrate that general ICU survivors return to pre-existing HR-QoL however it is unclear whether HR-QoL is disproportionately affected in patients with H1N1 influenza. The hypothesis was that mechanically ventilated Australasian adult survivors of H1N1 influenza would have worse HR-QoL than the healthy population one year following ICU discharge. Method(s): A prospective observational cohort study was conducted with institutional review board approval. Eligible participants were admitted to ICU and mechanically ventilated with a confirmed diagnosis of H1N1 influenza from eleven ICUs in Australia and New Zealand during the period June-September, 2009. People were excluded if aged < 18 years or they could not speak English. Eligible participants were contacted by letter and informed consent sought via a scripted telephone call. Demographic details were extracted from the Australian and New Zealand Intensive Care Influenza Investigators registry (INFINITE) and local intensive care databases. Two HR-QoL questionnaires validated in the ICU population were administered one year following ICU: Short Form-36 Version 2 (SF-36) and the Assessment of Quality of Life (AQoL). Result(s): Sixty-two people were recruited (48% male). The median (IQR) age was 42 (29 to 53) years, APACHE II score was 18.0 (14 to 20); ventilation days were 10.0 (4 to 23); ICU and hospital LOS was 12.5 (7 - 27) and 20.0 (15 - 38) days respectively. Hospital mortality was 7% and 31% of the cohort received a tracheostomy. The mean (SD) health utility score at one year

The use of extracorporeal membrane oxygenation (ECMO)for severe acute respiratory failure (ARF) in adults is growing rapidly given recent advances in technology, even though there is controversy regarding the evidence justifying its use. Because ECMOis a complex, high-risk, and costly modality, at present it should be conducted in centers with sufficient experience, volume, and expertise to ensure it is used safely. This position paper represents the consensus opinion of an international group of physicians and associated health-care workers who have expertise in therapeutic modalities used in the treatment of patients with severe ARF, with a focus on ECMO. The aim of this paper is to provide physicians,ECMOcenter directors and coordinators, hospital directors, health-care organizations, and regional, national, and international policy makers a description of the optimal approach to organizing ECMO programs for ARF in adult patients. Importantly, this will help ensure that ECMO is delivered safely and proficiently, such that future observational and randomized clinical trials assessing this technique may be performed by experienced centers under homogeneous and optimal conditions. Given the need for further evidence, we encourage restraint in the widespread use of ECMO until we have a better appreciation for both the potential clinical applications and the optimal techniques for performing ECMO.Copyright © 2014 by the American Thoracic Society.

ObjectivesIn the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols.DesignRetrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock.SettingICUs of Acute Respiratory Distress Syndrome Network participating hospitals.PatientsFive hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite.InterventionsFluid management by protocol.Measurements and main resultsCumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, -136 ± 491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ± 0.3) were equivalent to FACTT Conservative (14.6 ± 0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ± 0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite).ConclusionsFACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite

Learning Objectives 1. To learn about the different types of sclerosing agents and their properties 2. To learn about the specific indications for the use of sclerosing agents 3. To learn about techniques for the use of sclerosing agents including endpoints In a medical sense, sclerosis is defined as the stiffening or hardening of a structure, most freqently due to replacement of the normal tissue with connective tissue. It may also be defined as a resistance to change. When treating vascular malformations, it may often feel like we are trying to perform the former while the malformation is adhering to the latter. There are a wide variety of sclerosant agents available. Their method of action is to destroy and disrupt the vascular or lymphatic endothelium with subsequent vascular thrombosis and fibrosis. All act at the capillary or small channel level and many of them are potentially toxic and should be used with extreme care. If one were to design the ideal sclerosant, it would permanently obliterate the malformation being treated, be easily controllable and confined to the lesion and be non-toxic in both the long- and short-term. Unfortunately, no such agent exists, and we are left with a compromise of agents which vary widely in their efficacy, toxicity and complication profile. Commonly used sclerosant agents include but are not limited to * Venous sclerosants * Concentrated ethanol * Sodium tetradecyl sulphate (STS) * Polydocanol * Ethanolamine * Lymphatic sclerosants * All of the above plus * Doxycycline * Bleomycin * OK432 * Acetic acid * Hypertonic dextrose Commonly used venous agents include ethanol and STS. Ethanol denatures endothelial proteins and induces an intense inflammatory reaction. The use of ethanol carries a significant risk profile. In the literature, the recommended maximum dose is 1 ml/kg. In practice, it is rare to require more than 0.5 ml/kg; if doses greater than this are required to treat very large venous malformations, consideration sho

Learning Objectives 1. To learn about the different types of sclerosing agents and their properties 2. To learn about the specific indications for the use of sclerosing agents 3. To learn about techniques for the use of sclerosing agents including endpoints In a medical sense, sclerosis is defined as the stiffening or hardening of a structure, most freqently due to replacement of the normal tissue with connective tissue. It may also be defined as a resistance to change. When treating vascular malformations, it may often feel like we are trying to perform the former while the malformation is adhering to the latter. There are a wide variety of sclerosant agents available. Their method of action is to destroy and disrupt the vascular or lymphatic endothelium with subsequent vascular thrombosis and fibrosis. All act at the capillary or small channel level and many of them are potentially toxic and should be used with extreme care. If one were to design the ideal sclerosant, it would permanently obliterate the malformation being treated, be easily controllable and confined to the lesion and be non-toxic in both the long- and short-term. Unfortunately, no such agent exists, and we are left with a compromise of agents which vary widely in their efficacy, toxicity and complication profile. Commonly used sclerosant agents include but are not limited to * Venous sclerosants * Concentrated ethanol * Sodium tetradecyl sulphate (STS) * Polydocanol * Ethanolamine * Lymphatic sclerosants * All of the above plus * Doxycycline * Bleomycin * OK432 * Acetic acid * Hypertonic dextrose Commonly used venous agents include ethanol and STS. Ethanol denatures endothelial proteins and induces an intense inflammatory reaction. The use of ethanol carries a significant risk profile. In the literature, the recommended maximum dose is 1 ml/kg. In practice, it is rare to require more than 0.5 ml/kg; if doses greater than this are required to treat very large venous malformations, consideration sho

BACKGROUND: Recently, automated alerts have been used to identify patients with respiratory failure based on set criteria, which can be gleaned from the electronic medical record (EMR). Such an approach may also be useful for identifying patients with severe adult respiratory distress syndrome (ARDS) who may benefit from extracorporeal membrane oxygenation (ECMO). Inhaled nitric oxide (iNO) is a common rescue therapy for severe ARDS which can be easily tracked in the EMR, and some patients started on iNO may have indications for initiating ECMO. This case series summarizes our experience with using automated electronic alerts for ECMO team activation focused particularly on an alert triggered by the initiation of iNO. METHODS: After a brief trial evaluation, our Smart Alert system generated an automated page and e-mail alert to ECMO team members whenever a nonzero value for iNO appeared in the respiratory care section of our EMR. If iNO was initiated for severe respiratory failure, a detailed evaluation by the ECMO team determined if ECMO was indicated. For those patients managed with ECMO, we tabulated baseline characteristics, indication for ECMO, and outcomes. RESULTS: From September 2012 to July 2013, 45 iNO alerts were generated on 42 unique patients. Six patients (14%) met criteria for ECMO. Of these, four were identified exclusively by the iNO alert. At the time of the alert, the median PaO2-to-FIO2 ratiowas 64 mm Hg (range, 55-107 mm Hg), the median age-adjusted oxygenation index was 73 (range, 51-96), and the median Murray score was 3.4 (range, 3-3.75), indicating severe respiratory failure. Median time from iNO alert to ECMO initiation was 81 hours (range, -2 to 292 hours). Survival to hospital discharge was 83% in those managed with ECMO. CONCLUSION: Automated alerts may be useful for identifying patients with severe ARDS who may be ECMO candidates., Published in Journal of Trauma and Acute Care Surgery, v77 n3 s2 pS184-S189, 2014.

After a typhoon in September 2009, an outbreak of leptospirosis occurred in Metro Manila, the Philippines; 471 patients were hospitalized and 51 (10.8%) died. A hospitalbased investigation found risk factors associated with fatal infection to be older age, hemoptysis, anuria, jaundice, and delayed treatment with antimicrobial drugs., Emerging Infectious Diseases, 18(1), pp.91-94; 2012

Tumor necrosis factor alpha (TNF) is a mediator of injury in the critically ill. Its small molecular size (17 kd) should allow its clearance during continuous hemodiafiltration (CHD). The authors studied TNF extraction in 12 critically ill patients (APACHE II score 26.3 mean; range, 19-34) receiving CHD. Tumor necrosis factor levels were measured in prefiltered and filtered blood and ultradiafiltrate at 0.4 and 24 hours of therapy. Before CHD, mean plasma TNF levels were 261 pg/ml (95% confidence interval [CI]: 184-578) and 291 pg/ml (95% CI: 0-589) after 24 hours. There were no statistically significant differences between prefilter and postfilter TNF levels. Most ultradiafiltrate samples (74%) contained demonstrable TNF (mean, 314 pg/ml; 95% CI: 67-561). Daily TNF excretion was a mean of 15.9 micrograms (+5.6 standard error [SE]), with a mean daily clearance of 27.5 L (95% CI: 2.5-52.5). The authors conclude that significant amounts of TNF are excreted in the ultradiafiltrate during CHD. This observation may provide a rationale for use of similar therapies in critically ill patients in the absence of conventional indications for dialytic support.

Tumor necrosis factor alpha (TNF) is a mediator of injury in the critically ill. Its small molecular size (17 kd) should allow its clearance during continuous hemodiafiltration (CHD). The authors studied TNF extraction in 12 critically ill patients (APACHE II score 26.3 mean; range, 19-34) receiving CHD. Tumor necrosis factor levels were measured in prefiltered and filtered blood and ultradiafiltrate at 0.4 and 24 hours of therapy. Before CHD, mean plasma TNF levels were 261 pg/ml (95% confidence interval [CI]: 184-578) and 291 pg/ml (95% CI: 0-589) after 24 hours. There were no statistically significant differences between prefilter and postfilter TNF levels. Most ultradiafiltrate samples (74%) contained demonstrable TNF (mean, 314 pg/ml; 95% CI: 67-561). Daily TNF excretion was a mean of 15.9 micrograms (+5.6 standard error [SE]), with a mean daily clearance of 27.5 L (95% CI: 2.5-52.5). The authors conclude that significant amounts of TNF are excreted in the ultradiafiltrate during CHD. This observation may provide a rationale for use of similar therapies in critically ill patients in the absence of conventional indications for dialytic support.

Background: Clinical trials of induced hypothermia have suggested that this treatment may be beneficial in selected patients with neurologic injury. Objective(s): To review the topic of induced hypothermia as a treatment of patients with neurologic and other disorders. Design(s): Review article. Intervention(s): None. Main Result(s): Improved outcome was demonstrated in two prospective, randomized, controlled trials in which induced hypothermia (33degreeC for 12-24 hrs) was used in patients with anoxic brain injury following resuscitation from prehospital cardiac arrest. In addition, prospective, randomized, controlled trials have been conducted in patients with severe head injury, with variable results. There also have been preliminary clinical studies of induced hypothermia in patients with severe stroke, newborn hypoxic-ischemic encephalopathy, neurologic infection, and hepatic encephalopathy, with promising results. Finally, animal models have suggested that hypothermia that is induced rapidly following traumatic cardiac arrest provides significant neurologic protection and improved survival. Conclusion(s): Induced hypothermia has a role in selected patients in the intensive care unit. Critical care physicians should be familiar with the physiologic effects, current indications, techniques, and complications of induced hyperthermia.

Background: Clinical trials of induced hypothermia have suggested that this treatment may be beneficial in selected patients with neurologic injury. Objective(s): To review the topic of induced hypothermia as a treatment of patients with neurologic and other disorders. Design(s): Review article. Intervention(s): None. Main Result(s): Improved outcome was demonstrated in two prospective, randomized, controlled trials in which induced hypothermia (33degreeC for 12-24 hrs) was used in patients with anoxic brain injury following resuscitation from prehospital cardiac arrest. In addition, prospective, randomized, controlled trials have been conducted in patients with severe head injury, with variable results. There also have been preliminary clinical studies of induced hypothermia in patients with severe stroke, newborn hypoxic-ischemic encephalopathy, neurologic infection, and hepatic encephalopathy, with promising results. Finally, animal models have suggested that hypothermia that is induced rapidly following traumatic cardiac arrest provides significant neurologic protection and improved survival. Conclusion(s): Induced hypothermia has a role in selected patients in the intensive care unit. Critical care physicians should be familiar with the physiologic effects, current indications, techniques, and complications of induced hyperthermia.

OBJECTIVE:: Neutrophilic inflammation plays a key role in the pathogenesis of acute respiratory distress syndrome (ARDS) and acute lung injury (ALI). Positron emission tomography (PET) with [F]-fluoro-2-deoxy-d-glucose (FDG) can be used to image cellular metabolism that, during lung inflammatory processes, likely reflects neutrophils activity. The aim of this study was to assess the magnitude and regional distribution of inflammatory metabolic activity in the lungs of patients with ALI/ARDS by PET with FDG. DESIGN:: Prospective clinical investigation. PATIENTS:: Ten patients with ALI/ARDS; four spontaneously breathing and two mechanically ventilated subjects, without known lung disease, served as controls. INTERVENTIONS:: In each individual we performed an FDG PET/computed tomography of the thorax. MEASUREMENTS AND MAIN RESULTS:: FDG cellular influx rate constant (Ki) was computed for the imaged lung field and for regions of interest, grouping voxels with similar density. In all patients with ALI/ARDS, Ki was higher than in controls, also after accounting for the increased lung density. Ki values differed greatly among patients, but in all patients Ki of the normally aerated regions was much higher (2- to 24-fold) than in controls. Whereas in some patients the highest Ki values corresponded to regions with the lowest aeration, in others these regions had lower Ki than normally and mildly hypoaerated regions. CONCLUSION:: In patients with ALI/ARDS, undergoing mechanical ventilation since days, the metabolic activity of the lungs is markedly increased across the entire lung density spectrum. The intensity of this activation and its regional distribution, however, vary widely within and between patients. (C) 2009 Lippincott Williams & Wilkins, Inc.

Rationale: In a pulmonary process characterized by spatially heterogeneous loss of aeration, the impairment of gas exchange is expectedtodependonthe regional distribution of perfusion relative to that of aeration. Objectives: To investigate how regional aeration, shunt, and perfusion are interrelated at different levels of end-expiratory pressure and how their interplay relates to global shunt fraction in acute lung injury. Methods: Regional shunt and perfusion were assessed by imaging with positron emission tomography the pulmonary kinetics of [13N]nitrogen infused in saline solution in five sheep after lung lavage. The lung field was divided in six horizontal regions. Measurements and Main Results: Each animal showed an inverse relation betweenregional shunt (FS) and gas (FG) fractions: FS = -m·FG + FS 0. This relation was similar among animals (m = 1.25 ± 0.14, FS0 = 0.75 ± 0.15) and invariant with end-expiratory pressure, despite lack of correlation between global shunt and gas fractions and large interanimal variability in global shunt fraction. When this relation was used to estimate global shunt fraction as a perfusion-weighted average of the estimates of regional shunt fraction derived from regional gas fraction, 72% of the interanimal variability in global shunt fraction could be explained. Conclusions: Despite large interanimal variability in global shunt fraction, there was a consistent inverse relation between regional shunt and gas fractions, independent of end-expiratory pressure. Most of the interanimal variability in global shunt fraction could be explainedby thecombinedeffect of this relationandthe distribution of perfusion on regional shunt, rather than by differences in global aeration.

SCOPUS: ar.j, info:eu-repo/semantics/published

Tracheopathia osteoplastica is a benign cartilaginous and osseous metaplasia of the laryngo-tracheobronchial tree diagnosed more commonly in adults over 50 years of age. We report here the case of a 54-year-old man who underwent thyroidectomy for multinodular goiter. Immediately after an uneventful surgery, he developed an acute respiratory failure with radiologic picture of Adult Respiratory Distress Syndrome. Mechanical ventilation was set up again, bronchoscopy with biopsy disclosed a massive tracheobronchial haemorrhage from a tracheopathia osteoplastica. Supportive treatment was successfully provided and the patient resumed to a normal life 14 days after the operation., Case Reports, Journal Article, SCOPUS: ar.j, info:eu-repo/semantics/published

Tracheopathia osteoplastica is a benign cartilaginous and osseous metaplasia of the laryngo-tracheobronchial tree diagnosed more commonly in adults over 50 years of age. We report here the case of a 54-year-old man who underwent thyroidectomy for multinodular goiter. Immediately after an uneventful surgery, he developed an acute respiratory failure with radiologic picture of Adult Respiratory Distress Syndrome. Mechanical ventilation was set up again, bronchoscopy with biopsy disclosed a massive tracheobronchial haemorrhage from a tracheopathia osteoplastica. Supportive treatment was successfully provided and the patient resumed to a normal life 14 days after the operation., Case Reports, Journal Article, SCOPUS: ar.j, info:eu-repo/semantics/published

SCOPUS: ar.j, info:eu-repo/semantics/published

Interleukin 10 (IL-10) decreases the severity of experimental acute pancreatitis. The role of endogenous IL-10 in modulating the course of pancreatitis is currently unknown., SCOPUS: ar.j, info:eu-repo/semantics/published

A peptide-containing pulmonary surfactant has been developed, called KL - Surfactant. Assessment of activity and safety has been performed successfully in preterm subhuman primates and in 47 preterm human infants (IND %4O,287). This synthetic surfactant is now being tested in Adult human RDS.

Objective: oxygen supply dependency at normal or high oxygen delivery rate has been increasingly proposed as a hallmark and a risk factor in critical illnesses. We hypothesized that as fas as an adequate oxygen delivery is provided, oxygen consumption, when determined by indirect calorimetry, is not dependent on oxygen delivery in critically ill patients whereas calculated oxygen consumption is associated with artefactual correlation of oxygen consumption and delivery. Design: oxygen delivery, oxygen consumption and their relationship were analyzed prospectively. Metabolic data gained from both measured and calculated methods were obtained simultaneously before and after volume loading. Setting: the study was completed in the intensive care unit as part of the management protocol of the patients. Patients: 32 consecutive patients entered the study and were divided into 3 groups according to a clinical condition known to favour oxygen supply dependency: sepsis syndrome, adult respiratory distress syndrome and acute primary liver failure. Intervention: the rise in oxygen delivery was obtained by colloid infusion (oxygen flux test) performed in hemodynamically and metabolically stable patients. All were mechanically ventilated. No change in therapy was allowed during the test. Measurements and results: oxygen consumption was simultaneously evaluated by calculation (Fick Principle) and direct measurement using indirect calorimetry. Oxygen delivery was derived from the cardiac output (thermodilution) and arterial content of oxygen. Oxygen supply dependency was considered while observing an increase in oxygen delivery greater than 45 ml/min.m(2). Irrespective of patient's clinical diagnosis and outcome, measured oxygen uptake remained unaltered by volume infusion whereas both oxygen delivery and calculated oxygen consumption increased significantly. Arterial lactate level>2mmol/l and measured oxygen extraction ratio>25% failed to identify oxygen supply dependency when mea

SCOPUS: re.j, info:eu-repo/semantics/published

SCOPUS: re.j, info:eu-repo/semantics/published

The two basic mechanisms underlying most of the pleuropulmonary complications of severe acute pancreatitis include pulmonary atelectasis and alveolar flooding. Like in any abdominal catastrophy, pleural effusion and limited diaphragmatic excursion due to pain and intestinal atony are the main factors responsible for alveolar collaps and secondary infection. Physical therapy and needle pleural evacuation are the cornerstones of management. Owing to its pathophysiologic mechanisms adult respiratory distress syndrome is peculiar to acute pancreatitis. Alveolar capillary membrane injury is related to pancreatic necrosis, to its regional extent and to the subsequent overamplification of the inflammatory reaction. Diversion of those potential mediators of the syndrome either surgically or by thoracic duct drainage is essential in order to improve survival in these patients.

[No abstract available]

[No abstract available]