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Objectives: Thepurpose ofour study was tovalidate theincentive spirometry (IS) as a simple mean tofollow pulmonary function atthebedside after lung surgery. Materials andmethods: We studied prospectively 19patients (16 men,3women;mean±SEage, 60±2.8years) undergoing lobectomy forlung cancer.Allthepatients hadan obstructive pattern withFEV1/FVC below75%.Lungvolumes, including functional residual capacity (FRC) and residual volume(RV), measured using spirometry andthehelium dilution technique, andISwere measured preoperatively andpostoperatively atdays 1,2,3,and8,andat2months. Results: Ourresults showed that inthepostoperative period after lung resection, ISperformance was well correlated (R)during thefirst 8postoperative days withvital capacity (VC) (Rbetween 0.667and0.870) mainly duetotheexcellent correlation withtheinspiratory reservevolume(IRV, R between 0.680and0.895) butwas poorly correlated withexpiratory reservevolume(Rbelow 0.340), RV(Rbelow0.180), andFRC(Rbelow0.470). Conclusions: IScan beused as asimple mean tofollow lung function, especially VC andIRV, in thepostoperative period inspontaneously breathing patients. ISisnoninvasive andcan be performed repeatedly atthebedside intheintensive caresetting. (CHEST 1997; 111:559-63) Abbreviations: ERV=expiratory reservevolume; FRC=functional residual capacity; IRV=inspiratory reservevolume; IS=incentive spirometry; RV=residual volume; VC=vital capacity; VT=tidal volume

This prospective, double-blind study used invasive monitoring and echo-Doppler techniques to compare the hemodynamic effects of nebivolol, a new beta 1-selective beta-blocking agent with those of atenolol in patients recovering from coronary artery bypass grafting surgery. Five milligrams nebivolol and 50 mg atenolol equally decreased heart rate (HR) and blood pressure (BP) but, nebivolol, in contrast to atenolol, caused no decrease in stroke index (SI), cardiac index (CI), and right ventricular ejection fraction (RVEF). These differences appeared to be related in part to different peripheral effects of the two agents because nebivolol administration was associated with a reduction in systemic vascular resistance (SVR). After < or = 10 days of treatment, acceleration of aortic flow velocity increased and isovolumic relaxation time decreased with nebivolol but not with atenolol treatment. Both drugs were equally well tolerated. Therefore, nebivolol shares most of its effects with classical beta 1-blockers but is devoid of the potentially harmful effects on cardiac output (CO) and peripheral resistance.

The purpose of our study was to validate the incentive spirometry (IS) as a simple mean to follow pulmonary function at the bedside after lung surgery.We studied prospectively 19 patients (16 men, 3 women; mean +/- SE age, 60 +/- 2.8 years) undergoing lobectomy for lung cancer. All the patients had an obstructive pattern with FEV1/FVC below 75%. Lung volumes, including functional residual capacity (FRC) and residual volume (RV), measured using spirometry and the helium dilution technique, and IS were measured preoperatively and postoperatively at days 1, 2, 3, and 8, and at 2 months.Our results showed that in the postoperative period after lung resection, IS performance was well correlated (R) during the first 8 postoperative days with vital capacity (VC) (R between 0.667 and 0.870) mainly due to the excellent correlation with the inspiratory reserve volume (IRV, R between 0.680 and 0.895) but was poorly correlated with expiratory reserve volume (R below 0.340), RV (R below 0.180), and FRC (R below 0.470).IS can be used as a simple mean to follow lung function, especially VC and IRV, in the postoperative period in spontaneously breathing patients. IS is noninvasive and can be performed repeatedly at the bedside in the intensive care setting.

The relative contributions of oxygen delivery (DO2) and oxygen extraction (O2ER) to the increase in cellular oxygen uptake (VO2) after cardiopulmonary bypass were studied prospectively in 36 patients after coronary artery bypass grafting (n = 18), valve replacement (n = 17), and removal of a left atrial tumor (n = 1). VO2 was calculated from the Fick equation and DO2 from thermodilution cardiac output and arterial oxygen content. During the first 24 h after cardiac surgery, there was a strong relation between VO2 and DO2 (VO2 = 28 + 0.27 x DO2, r = 0.79, P0.0001) but not between VO2 and oxygen extraction. Mixed venous oxygen saturation (SVO2) was usually reduced when cardiac index was below 2.0 L.min-1.m-2. Patients with a prolonged intensive care unit course (24 h) had lower cardiac index and lower SVO2 than the other patients. Therefore, the progressive increase in VO2 after cardiac surgery is accomplished primarily by an increase in cardiac output and DO2. It is usually when cardiac function is compromised that O2ER increases and SVO2 decreases.

The evolutions of the medical art, of the medical ethics and of the society create a new concept: the quality of life. The well-being of the patients has to be determined by the patients themselves but some general rules have been found essentially for the old patient.

Cytokines have been associated with the development of sepsis and diffuse tissue injury following septic or endotoxic challenges in humans. Furthermore, relative organ-system dysfunction, not specific organ dysfunction, appears to predict outcome from critical illness. We hypothesized that persistence of inflammatory cytokines within the circulation, reflecting a generalized systemic inflammatory response, is associated with multiple-system organ failure (MSOF) and death from critical illness. In addition, since hepatic function is central to host-defense homeostasis, we further reasoned that critically ill patients with hepatic cirrhosis would have an increased incidence of MSOF and death following sepsis associated with a persistence of cytokines in the blood.We measured serum levels of tumor necrosis factor (TNF), interleukin (IL) 1, IL-2, IL-6, and interferon gamma (IFG) serially for the first 48 h following the onset of hypotension (systolic blood pressure90 mm Hg) thought likely to be due to sepsis in all patients presenting to one ICU. These data were correlated with initial severity of shock and retrospective determination of septic or nonseptic origin, preexistent hepatic cirrhosis, subsequent development of MSOF, and outcome.Fifty-three specific episodes of shock in 52 patients were recorded (35 septic and 18 nonseptic episodes). Mortality was higher in septic patients (41 vs 17 percent, p0.01), as was the development of MSOF (29 vs 6 percent, p0.001), incidence of cirrhosis (21 vs 0 percent, p0.01), and TNF levels over the study interval (p0.01). Nonseptic patients also had an initial elevation in TNF over 48-h levels (p0.05) that were higher than serum levels reported for normal subjects (chi 2, p0.05). There was no relation between peak TNF level and outcome. Sixty-seven percent of the cirrhotic patients had development of MSOF and died, while only 30 percent of the noncirrhotic patients had development of MSOF or died (p0.05). The TNF and IL-6 levels in patients who had MSOF or who died were both elevated and did not decrease over time independent of presence or absence of sepsis (p0.01). Similarly, IL-6 levels after 12 h were higher in cirrhotic patients than in noncirrhotic septic patients (p0.05). No elevation in IL-1, IL-2, or IFG was seen in any patient subpopulation.TNF and IL-6 serum levels are higher in septic than in nonseptic shock, but the persistence of TNF and IL-6 in the serum rather than peak levels of cytokines predicts a poor outcome in patients with shock.

In this pilot study, murine monoclonal anti-TNF antibody (2 mg/kg) was administered to ten patients within 24 h of septic shock which persisted after initial resuscitation with intravenous fluids and adrenergic agents. This treatment resulted in a reduction in heart rate (from 122 +/- 10 to 113 +/- 10 beats per minute at 4 h, p less than 0.01) associated with an increase in LVSWI (from 26.5 +/- 5.6 to 31.5 +/- 10.5 g.m2 at 2 h, p less than 0.05), indicating in the absence of change in cardiac filling pressures, an improvement in ventricular function. Arterial oxygenation improved concurrently in six patients. These changes, however, appeared transient. The improvement in cardiac function following anti-TNF antibody administration in patients is in keeping with recent experimental studies indicating the role of TNF in the myocardial depression characterizing septic shock.

The present study explored the possibility of using a short-term dobutamine infusion to disclose oxygen uptake/supply dependency. The effects of a standard dose of 5 micrograms/kg/min of dobutamine on oxygen-derived variables were studied in 73 acutely ill patients with heart failure (n = 24) or sepsis (n = 49). In each group, patients were separated according to their blood lactate concentrations (either above or below 2 mEq/L). In all patient groups, dobutamine resulted in significant increases in cardiac output and oxygen transport. However, oxygen consumption increased significantly only in patients with elevated blood lactate levels (cardiac failure: from 108 +/- 26 to 131 +/- 25 ml/min/M2, n = 8, p less than 0.01; sepsis: from 139 +/- 44 to 167 +/- 68 ml/min/M2, n = 16, p less than 0.01) and not in the other patients (heart failure: from 121 +/- 29 to 115 +/- 31 ml/min/M2, n = 28, NS; sepsis: from 158 +/- 39 to 166 +/- 45 ml/min/M2, n = 21, NS). These data, therefore, indicate that dobutamine at the dose used does not increase oxygen consumption in critically ill patients unless there is coexistent tissue hypoxia reflected by increased blood lactate levels. A short-term dobutamine infusion can be used to disclose an oxygen uptake/supply dependency phenomenon.

In 14 critically ill patients in stable cardiopulmonary status, right ventricular ejection fraction (RVEF) was measured by thermodilution technique and by radionuclear (gated first pass) technique. The pulmonary artery catheter was equipped with a fast-response thermistor and an intracardiac ECG monitor. In addition, the proximal lumen ended in a 3-hole port 21 cm from the tip of the catheter to facilitate mixing of the cold bolus above the tricuspid valve. The use of a new algorithm based on an exponential curve analysis of the thermodilution curve limited the variability of RVEF determinations to 7.6%. The correlation between RVEF measured by thermodilution and radionuclear techniques was significant (y = 12.7 +/- 0.49x, r = 0.67, p less than 0.01). However, the values obtained by thermodilution were usually lower, especially for high RVEF. Nevertheless, although some discrepancy was found, thermodilution techniques allow simple, accurate and repetitive bedside measurements of right ventricular volumes in the critically ill.

In a cirrhotic patient who presented with cardiogenic pulmonary edema rapidly complicated by severe circulatory shock, magnesium depletion was diagnosed on the basis of a history of heavy alcohol intake, frequent myoclonias and low serum magnesium concentration. Magnesium infusion resulted in a dramatic increase in cardiac work associated with a rapid and definitive resolution of circulatory shock.

SummaryA case of hypertrophie osteo-arthropathy (disease of Pierre-Marie-Bamberger) is described. The authors discuss the pathogenic theories of this syndrome, and consider tat none is completely satisfactory.

Advances in emergency medicine and resuscitation have changed the direct prognosis of some critically ill states and have induced an evolution in the old and traditional definitions of death: from the prolonged absence of breathing to the cessation of function of the entire brain, including the brain stem.

Advances in resuscitation and intensive care medicine, made over the past 30 years, have had an impact on the definition of death. For millenia, the signs of death have not been controversial: the most commonly employed criterion was absence of “breathing,” explaining common locutions such as “he drew his last breath” or “this man has expired.” Cardiac definition of death is also very old; the awareness of cardiac function was more difficult and sophisticated until recent progress in electrocardiography and cardiac monitoring.

In a 18 year-old woman, an isolated benign hemangioma of the right atrium led to cardiac tamponade and acute renal failure. After 8 days of anuria, the tumor was excised and replaced by a pericardial patch. The persistence of severe renal shutdown necessitated further hemodialysis during 22 days postoperatively. The patient was discharged on the 45th day in good hemodynamic and renal condition. Thirteen cases of benign hemangioma of the heart have been reported in the literature: 12 were found at autopsy; only 4 were complicated by hemopericardium but none of these survived.

Publisher Summary This chapter describes the evolution of lactacidemia during treatment of circulatory shock. The chapter presents the investigation of spontaneous recovery from lactic acidosis after grand-mal seizures in eight patients. The rate of disappearance of excess blood lactate during successful treatment of circulatory shock would be of physiological and clinical interest. The time course of lactacidemia during treatment of severe circulatory shock in 11 patients was studied. The results were compared to those of four patients who were recovering from grand-mal seizures. The study group included eight men and seven women, ranging in age from 34 to 87 years. Patients with hepatic disease, neoplasm, drug intoxication, or decompensated diabetes mellitus were excluded. During the first hour after seizures had stopped, blood lactate concentration dropped by half and most of the decrease occurred during the first 15–20 min. This model is peculiar in that a transient lactic acid overproduction abruptly ceases, whereas lactate elimination is unaffected. In circulatory shock, the resolution of lactic acidosis is expected to be considerably slower, even in the presence of a dramatic clinical improvement.

The incidence of hypophosphatemia during the first 48 h following cardiothoracic surgery was prospectively studied in 74 patients. Hypophosphatemia, defined by a serum phosphate below 2.50 mg/dl, was observed in 19 of 34 (56%) patients after thoracic surgery and in 20 of 40 (50%) patients after cardiac surgery. As a whole, hypophosphatemia occurred earlier after thoracic than after cardiac surgery. After thoracic surgery, hypophosphatemia was milder for patients in whom bleeding was more severe. The anticoagulant solution CPD used in stored blood was identified as an important source of phosphate. These results indicate hypophosphatemia is a common finding after cardiothoracic surgery. Since severe hypophosphatemia can be related to phosphate depletion, phosphate supplements could be warranted especially during thoracic surgery when blood transfusions are less than 1000 ml.

We randomly assigned 425 outpatients, independently classified as primarily depressed by two trained psychiatrists, to double-blind treatment with Imipramine hydrochloride, chlordiazepoxide hydrochloride, or placebo. Those patients who remained at least moderately depressed (following a two-week placebo washout period) were treated for an additional eight weeks. An endpoint analysis of 387 patients who completed two or more weeks of medication disclosed early therapeutic advantages of chlordiazepoxide. By week 4 of treatment, however, imipramine produced more improvement than did placebo and chlordiazepoxide. By six and eight weeks a general, marked therapeutic advantage was found for imipramine relative to placebo and to chlordiazepoxide on measures of depression, anxiety, anger-hostility, interpersonal sensitivity, and global improvement. Chlordiazepoxide-treated patients generally did significantly better on sleep difficulty but significantly worse on anger-hostility and interpersonal sensitivity than did imipramine- or placebo-treated patients.

A patient with miliary tuberculosis developed the adult respiratory distress syndrome. The diagnosis of tuberculosis was not made especially because of several negative bacteriological examinations and of initial radiological aspects. Patient died of respiratory failure complicated with disseminated intravascular coagulation. This straightens the hypothesis of a physiopathological relationship between the two syndromes. The necessity of anti-tuberculous therapy should be evocated in every situation of adult respiratory distress syndrome of unknown origin.