Advantage of spontaneous breathing in patients with respiratory failure (Views : 7155 times)
The fact that different modalities of mechanical ventilation are associated with a number of serious side effects and risks and can influence the clinical outcome of patients, the various modes of mechanical ventilation have, over the past ten years, been the subject of a wide variety of scientific studies. Many of these modalities are designed for partial ventilatory support, which might reflect the complexity of the issue of patient's ventilator interactions when spontaneous breathing activity is present, compared to controlled mechanical ventilation. Spontaneous breathing modes during mechanical ventilation may integrate intrinsic feedback mechanisms that should help prevent ventilator- induced lung injury and improve synchrony between the ventilator and the patient's demand. The improvements in pulmonary gas exchange, systemic blood flow, and oxygen supply to the tissue that have been observed when spontaneous breathing has been maintained during mechanical ventilation are reflected in the clinical improvement in the patient' s condition. It is the aim of this article to review the effects of preserved spontaneous breathing activity during mechanical ventilation in patients with acute respiratory failure.
Key words: mechanical ventilation, acute respiratory distress syndrome, ventilation mode, spontaneous breathing
The addition of enteral to parenteral antimicrobials may prolong antibiotic era (Views : 2912 times)
Resistance to parenteral antimicrobials generally occurs within two years after introduction into general use. The site where de novo resistance develops has been acknowledged to be the gut. Overgrowth of abnormal flora, defined as 105 potential pathogens per g of faeces is a risk factor for resistance following increased spontaneous mutation leading to polyclonality and antimicrobial resistance. As parenteral antimicrobials generally fail to eradicate the abnormal carrier state in overgrowth concentrations due to sub-lethal concentrations in bile and mucus the enteral antimicrobials polymyxin/tobramycin aiming at converting the abnormal carrier state into normal carriage, are the essential component of selective decontamination of the digestive tract (SDD), because they eradicate carriage and overgrowth including resistant mutants, maintaining the usefulness of parenteral antimicrobials.
Keywords: normal carriage, abnormal carriage, overgrowth, mutation, polyclonality, resistance, selective decontamination of the digestive tract, parenteral antimicrobials, enteral antimicrobials
Baseline characteristics, time-to-hospital admission and in-hospital outcomes of patients hospitalized with ST-segment elevation acute coronary syndromes, 2002 to 2005 (Views : 2213 times)
Objective. The purpose of this study was to retrospectively determine baseline patient characteristics, time-to-hospital admission, utilization of reperfusion therapy and outcomes of patients hospitalized with ST-segment elevation acute coronary syndromes (ACS) between 2002 and 2005, particularly after 24-h primary percutaneous coronary intervention (PCI) was introduced in 2004.
Methods. Included were all patients admitted to the intensive care unit (ICU) from 2002 to 2005 who met the criteria for ACS. Information on patients' demographic characteristics, medical history, time-to-hospital admission, clinical characteristics on admission, laboratory examinations, ECG findings, treatments, hospital duration, and in-hospital outcomes was collected by completing a standardized case report form.
Results. There was a sustained increase in admissions between 2002 and 2005, altogether 899 patients were hospitalized. A significant decrease in time-to-hospital admission was achieved. More patients arrived within 4-6 hours (16.3% in 2002 vs. 31.5% in 2005) and less after 12 hours (35.0% in 2002 vs. 13.4% in 2005). A significant increase in primary PCI rate was achieved (16.9% in 2002 vs. 90% in 2005, P<0.001). Consequently, the rate of thrombolysis, postponed PCI and nonreperfusion medical therapy decreased. From 2002 to 2005, total in-hospital stay decreased significantly (15.4±13.0 days vs. 7.8±8.5 days, P<0.001), in-hospital mortality insignificantly (11.3% vs. 7.2%).
Conclusion. Despite the significant increase in primary PCI between 2002-2005, there was only an insignificant decrease in in-hospital mortality. Further shortening the time-to-hospital admission and increasing primary PCI among older hemodynamically unstable ACS patients, particularly those with cardiogenic shock, could achieve an additional decrease in mortality.
Key words: acute coronary syndrome, acute myocardial infarction, time-to-hospital admission, prognosis, management, percutaneous coronary intervention, mortality
Tracheotomy versus prolonged intubation in medical intensive care unit patients (Views : 37705 times)
Introduction. The contribution of tracheotomy in comparison to intubation in patients on the resuscitation ward is debated. The main purpose of our study is to assess if tracheotomy compared to prolonged intubation, reduces the whole duration of ventilation, the frequency of nosocomial pneumopathy, the mean duration of hospitalisation in the resuscitation ward and mortality.
Patients and method. It is a retrospective and comparative study between two groups of patients who presented neurological or respiratory pathology and required mechanical ventilation for more than three weeks. The study lasted 7 years and involved 60 patients divided into 2 groups : the Tracheotomy Group (TG, n=30), in which a tracheotomy was performed between the eighth day and the fifteenth day, after the first period of tracheal intubation; and the Intubation Group (IG, n=30), where the patients were intubated throughout the period of hospitalization until extubation or death. We monitored the whole duration of ventilation, the frequency of nosocomial pneumopathy, the incidence of each technique as well as the mean duration of hospitalization in the resuscitation ward and the mortality rate. The two groups were similar in age, sex and gravity score : SAPS II and APACHE II.
Results. The results showed a significant statistical decrease of the whole duration of mechanical ventilation for the TG: 27.03 ± 3.31 days versus 31.63 ± 6.05 days for the IG (P = 0.001). However, there is no significant difference between the two groups, whereas the frequency of nosocomial pneumopathy is about 53.3% in the group with tracheotomy versus 70% for the intubated group (P = 0.18). This shows, on the other hand, the late prevalence of nosocomial pneumopathy in the tracheotomy group patients.
We noticed one case of bleeding after tracheotomy. Sinusitis was also diagnosed but without a significant difference between the two groups, 6.7% (2 cases) in the TG and 10% (3 cases) for the IG (P = 0.31). The mean duration of hospitalization didn't differ between the two groups; it was 30.96 ± 9.47 days for the TG versus 34.26 ± 9.74 days for the IG (P = 0.10). The study shows that there is no statistically significant difference in mortality between the two groups, 26.7% in the TG versus 46.7% for the IG (P = 0.10).
Conclusion. It seems that tracheotomy, in medical ICU patients, leads to a shorter duration of ventilation, delayed nosocomial pneumopathy without the modification of its frequency and the mean duration of hospitalization or death.
Keywords: tracheotomy, prolonged intubation, pneumopathy, mechanical ventilation, mortality
Relationship between mean arterial pressure and end-tidal partial pressure of carbon dioxide during (Views : 24201 times)
Objectives. We examined the relationship between partial end-tidal CO2 (pet) and mean arterial pressure in patients with traumatic hemorrhagic shock, who were receiving constant minute ventilation.
Methods. In 61 patients we continuously measured pet CO2 with a capnograph, direct arterial pressure via a cannula, oxygen levels via pulse oximetry and body temperature.
Results. We observed significant changes in pet CO2 (increase) after volume resuscitation and a quantitative linear relationship between pet CO2 and mean arterial pressure.
Conclusions. Partial end-tidal CO2 can be used as a reliable non-invasive monitoring device in patients with hemorrhagic shock when minute ventilation is relatively constant. The monitoring of pet CO2 might also be a useful guide for volume resuscitation in hemorrhagic shock, especially in the pre-hospital setting.
Keywords: end- tidal CO2, mean arterial pressure, hemorrhagic shock, relationship