1/199. fibrinolytic agents: a new approach to the treatment of adult respiratory distress syndrome.Nineteen patients suffering from adult respiratory distress syndrome (ARDS) secondary to trauma or sepsis, or both, failed to respond to treatment with mechanical ventilation with oxygen and positive end-expiratory pressure. On the premise that ARDS may be caused by the microclots of disseminated intravascular coagulation obstructing the pulmonary microcirculation, the patients were treated with either streptokinase or urokinase. Eighteen patients responded with significant improvement in PaO 2 value. No bleeding occurred and clotting parameters remained normal.- - - - - - - - - - ranking = 1keywords = trauma (Clic here for more details about this article) |
2/199. phrenic nerve injury following cardiac surgery: a review.phrenic nerve injury following cardiac surgery is variable in its incidence depending on the diligence with which it is sought. Definitive studies have shown this complication to be related to cold-induced injury during myocardial protection strategies and possibly to mechanical injury during internal mammary artery harvesting. The consequences are also variable and depend to a large extent on the underlying condition of the patient, particularly with regard to pulmonary function. The response of the patient may range from an asymptomatic radiographic abnormality to severe pulmonary dysfunction requiring prolonged mechanical ventilation and other associated morbidities and even mortality. Two cases are presented to demonstrate the variability in clinical responses to diaphragmatic dysfunction secondary to phrenic nerve injury from cardiac surgery. In addition, treatment strategies are reviewed including early tracheostomy and diaphragmatic plication, which appear to be the most effective options for patients who are compromised by phrenic injuries.- - - - - - - - - - ranking = 1204.0988542065keywords = injury (Clic here for more details about this article) |
3/199. The pathology of transfusion-related acute lung injury.Transfusion-related acute lung injury is an uncommon condition characterized by the rapid onset of respiratory distress soon after transfusion. Our understanding of its pathophysiology is based on animal models of complement (C5a) and antibody-induced lung injury and a limited number of autopsies. These models suggest that transfusion-related acute lung injury is induced by granulocytes that aggregate in the pulmonary microvasculature after activation by transfusion-derived antibodies or biologically active lipids. The published autopsy reports provide little support for this model, as they are invariably confounded by underlying pulmonary infection, preexisting disease, and resuscitation injury. We report the case of a previously well 58-year-old man who died of transfusion-related acute lung injury within 2 hours of the onset of pulmonary distress; autopsy showed evidence of massive pulmonary edema with granulocyte aggregation within the pulmonary microvasculature and extravasation into alveoli. Electron microscopy revealed capillary endothelial damage with activated granulocytes in contact with the alveolar basement membranes. These findings provide direct support for the proposed model of transfusion-related acute lung injury pathogenesis.- - - - - - - - - - ranking = 1505.1235677581keywords = injury (Clic here for more details about this article) |
4/199. Corticosteroid rescue in late paediatric acute respiratory distress syndrome.Late acute respiratory distress syndrome (ARDS) is associated with a mortality of more than 80%. Recent reports in adults have shown improved survival in late ARDS treated with prolonged course of steroids, however little data are available in children concerning its safety and efficacy. We report the successful treatment of a child dying from refractory late ARDS using a prolonged course of high-dose methylprednisolone instituted after 12 days of advanced mechanical ventilation. Progressive improvement was seen from days 3, 7, 10 and 14 after treatment with improvement in PaO2/fraction of inspired oxygen (FiO2) ratios, lung injury score and chest radiographical score. Treatment was complicated by a fungal urinary tract infection that was easily controlled. There were no major metabolic side effects. Steroid therapy can be considered in the treatment of children with refractory late ARDS but larger prospective studies are needed to define indications, timing, dosing and safety of this mode of treatment in children.- - - - - - - - - - ranking = 150.51235677581keywords = injury (Clic here for more details about this article) |
5/199. Transfusion-related acute lung injury due to granulocyte-agglutinating antibody in a patient with paroxysmal nocturnal hemoglobinuria.BACKGROUND: Transfusion-related acute lung injury (TRALI) is usually reported after the transfusion of blood components from donors with white cell (WBC) antibodies, but only very rarely if the patient has these antibodies. The pathogenesis of TRALI is not fully understood. Not all transfusion recipients develop TRALI, even though WBC antibodies are present in the donor or the recipient. CASE REPORT: A patient with paroxysmal nocturnal hemoglobinuria (PNH) who developed TRALI after the transfusion of non-WBC-reduced red cells is described. Granulocyte-agglutinating anti-5b was detected in his serum, and the crossmatch with the donor granulocytes was positive. The patient also developed a severe exacerbation of hemolysis with renal failure; serologic results excluded an immune hemolytic posttransfusion reaction. The patient recovered from both events after about 1 week. CONCLUSION: Granulocyte-agglutinating antibodies present in the recipient play an important role in TRALI, and also other factors may contribute to its pathogenesis. The reaction between the PNH patient's antibody (anti-5b) and transfused WBCs was found not only to be responsible for the respiratory distress but also to have triggered, through the innocent-bystander mechanism of complement activation, an intensive hemolysis, which was very likely a contributing factor in the development of TRALI.- - - - - - - - - - ranking = 752.56178387906keywords = injury (Clic here for more details about this article) |
6/199. Pressure limited ventilation with permissive hypoxia and nitric oxide in the treatment of adult respiratory distress syndrome.In the management of adult respiratory distress syndrome pressure limited mechanical ventilation may protect the lungs from overdistention injury. Unacceptable hypoxia may be avoided by adding nitric oxide to the inspiratory gas, and thus make pressure limited ventilation easier to perform. There exists no consensus about an acceptable lower limit of SaO2, and in the present case we gave preference to pressure limitation at the cost of oxygenation. A young woman with severe adult respiratory distress syndrome was set on pressure limited mechanical ventilation with peak pressures of 35-38 cm H2O, PEEP of 10-12 cm H2O, and FiO2 of 0.95 with 20 ppm nitric oxide. SaO2 varied between 75 and 85%, and cardiac output ranged between 5.2 and 7.5 L min-1. oxygen consumption was in the upper normal range, and she did not became acidotic. After 3 days, she started to improve. In conclusion, it seems that hypoxia might be well tolerated as long as the circulation is not compromised. It might prove beneficial to accept some hypoxia to avoid ventilator induced lung damage.- - - - - - - - - - ranking = 150.51235677581keywords = injury (Clic here for more details about this article) |
7/199. A case for steroids in acute lung injury associated with the retinoic acid syndrome.A 62-year-old woman with acute promyelocytic leukaemia was treated with all-trans retinoic acid. On day 2 she suffered with dyspnoea and general fatigue. Marked hypoxia suggested the occurrence of retinoic acid syndrome. She underwent endotracheal intubation and mechanical ventilation with the administration of dexamethasone. Her symptoms promptly abated. She was subsequently treated with conventional chemotherapy and achieved complete remission.- - - - - - - - - - ranking = 602.04942710325keywords = injury (Clic here for more details about this article) |
8/199. Extracorporeal support in an adult with severe carbon monoxide poisoning and shock following smoke inhalation: a case report.The objective of this study was to discuss the case of a patient with severe smoke inhalation-related respiratory failure treated with extracorporeal support. The study was set in a 12-bed multi-trauma intensive care unit at a level one trauma center and hyperbaric medicine center. The patient under investigation had carbon monoxide poisoning, and developed acute respiratory distress syndrome and cardiovascular collapse following smoke inhalation. Rapid initiation of extracorporeal support, extreme inverse-ratio ventilation and intermittent prone positioning therapy were carried out. Admission and serial carboxyhemoglobin levels, blood gases, and computerized tomography of the chest were obtained. The patient developed severe hypoxia and progressed to cardiovascular collapse resistant to resuscitation and vasoactive infusions. Veno-venous extracorporeal support was initiated. Cardiovascular parameters of blood pressure, cardiac output, and oxygen delivery were maximized; oxygenation and ventilation were supported via the extracorporeal circuit. Airway pressure release ventilation and intermittent prone positioning therapy were instituted. Following 7 days of extracorporeal support, the patient was decannulated and subsequently discharged to a transitional care facility,neurologically intact. smoke inhalation and carbon monoxide poisoning may lead to life-threatening hypoxemia associated with resultant cardiovascular instability. When oxygenation and ventilation cannot be achieved via maximal ventilatory management, extracorporeal support may prevent death if initiated rapidly.- - - - - - - - - - ranking = 2keywords = trauma (Clic here for more details about this article) |
9/199. Use of recruitment maneuvers and high-positive end-expiratory pressure in a patient with acute respiratory distress syndrome.OBJECTIVE: To present the use of a novel high-pressure recruitment maneuver followed by high levels of positive end-expiratory pressure in a patient with the acute respiratory distress syndrome (ARDS). DESIGN: Observations in one patient. SETTING: The medical intensive care unit at a tertiary care university teaching hospital. PATIENT: A 32-yr-old woman with severe ARDS secondary to streptococcal sepsis. INTERVENTIONS: The patient had severe gas exchange abnormalities because of acute lung injury and marked lung collapse. Attempts to optimize recruitment based on the inflation pressure-volume (PV) curve were not sufficient to avoid dependent lung collapse. We used a recruitment maneuver using 40 cm H2O of positive end-expiratory pressure (PEEP) and 20 cm H2O of pressure controlled ventilation above PEEP for 2 mins to successfully recruit the lung. The recruitment was maintained with 25 cm H2O of PEEP, which was much higher than the PEEP predicted by the lower inflection point (P(Flex)) of the PV curve. MEASUREMENTS AND MAIN RESULTS: Recruitment was assessed by improvements in oxygenation and by computed tomography of the chest. With the recruitment maneuvers, the patient had a dramatic improvement in gas exchange and we were able to demonstrate nearly complete recruitment of the lung by computed tomography. A PV curve was measured that demonstrated a P(Flex) of 16-18 cm H2O. CONCLUSION: Accumulating data suggest that the maximization and maintenance of lung recruitment may reduce lung parenchymal injury from positive pressure ventilation in ARDS. We demonstrate that in this case PEEP alone was not adequate to recruit the injured lung and that a high-pressure recruitment maneuver was required. After recruitment, high-level PEEP was needed to prevent derecruitment and this level of PEEP was not adequately predicted by the P(Flex) of the PV curve.- - - - - - - - - - ranking = 301.02471355162keywords = injury (Clic here for more details about this article) |
10/199. adult respiratory distress syndrome complicating plasmodium falciparum malaria.In people who do not have clinical immunity to malaria, infection with the malaria parasite could lead to severe complications. We describe a patient who had acute and severe lung injury from malaria. A 37-year-old woman had a 24-hour history of generalized weakness and chills 2 days after returning from nigeria. She had received mefloquine as prophylaxis, but the patient did not take the medication. On admission, a thick blood smear revealed severe plasmodium falciparum parasitemia. She was given doxycycline and quinine, but as her parasitemia resolved, dyspnea and hypoxemia developed and she consequently required placement of an endotracheal tube. Chest radiography results showed bilateral and diffuse infiltrate. This report shows that patients with P falciparum malaria should be monitored closely and transferred to an intensive care unit for additional management if respiratory distress develops. physicians caring for patients who have recently traveled to malaria-endemic areas need to anticipate the possible development of malaria with all of its complications, including acute lung injury.- - - - - - - - - - ranking = 301.02471355162keywords = injury (Clic here for more details about this article) |
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