Volume 4 Number 2

Diluted porcine surfactant lung lavages in children with severe ARDS (Views : 3174 times)

Abstract

Acute respiratory distress syndrome (ARDS) is characterized by damage to the arteriolar-capillary endothelium and alveolar epithelium that leads to surfactant deficiency and atelectasis.  Alveolar collapse and pulmonary edema will further induce surfactant inactivation. Surfactant supplementation has been suggested but results are unpredictable. Poor response may be due to inhibition of administered surfactant by plasma components filling the alveolar space, severity of lung injury, time of surfactant application and inadequate dose. We report the course of gas exchange and pulmonary mechanics after instillation  of surfactant in 14 children (3 months-7 years) with severe ARDS, defined as an oxygenation index (OI) > 30 and a partial pressure of oxygen/ fraction of Inspired oxygen (PaO2/FiO2) 200 for more than 12 hours.  Diluted surfactant lung lavages were able to increase blood gas exchange in all our patients despite previously severe gas exchange impairment.

Keywords: ARDS, pulmonary surfactant, bronchoalveolar lavages, child

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Does inhalation injury increase the mortality rate in burn patients? Investigation of relationship between inhalation injury and severity of burn surface (Views : 4386 times)

Abstract

Objective. Inhalation injury accounts for 20% to 80% of deaths in burn patients due to severe cardiopulmonary distress not seen in cutaneous injury alone.   However, there are few comparative studies or retrospective analyses of the injury severity or deaths of patients with inhalation injury.

Methods.  We evaluated 59 patients (31 with inhalation injury and 27 without inhalation injury) who had sustained a severe burn injury and were treated in the intensive care unit at our medical center from 2004 through 2006.   Of the 31 patients with inhalation injury, 14 (45.2%) died, and of the 27 without inhalation injury, 4 (16.7%) died.

Results.  We investigated specific aspects of the severity and mortality of burn patients.  The median (mean) burn index in patients without and with inhalation injury were 45 and 50 points (17.9 and 34.4), and the median (mean) prognostic burn index scores between patients with and without inhalation injury were 88.5 and 55.5 points (86.8 and 69.4). The median (mean) prognostic burn index scores in surviving patients with and without inhalation injury were 49.5 and 67 points (60.0 and 70.0), which suggest that patients with inhalation injury sustained significantly more severe cutaneous burns than did patients without inhalation injury.

Conclusions. We conclude that inhalation injury alone may be fatal, but many patients with inhalation injury also sustain more severe cutaneous burns, which can further increase the mortality rate.

Key words: inhalation injury, burn, burn index, mortality, prognostic burn index

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Comparison of remifentanil versus fentanyl general anesthesia for short outpatient urologic procedures (Views : 9815 times)

Abstract

Study objectives. To compare the effect of remifentanil versus fentanyl isoflurane general anesthesia on Aldrete score, emergence, extubation and discharge times from the operating room (OR) and postanesthesia care unit (PACU) following short outpatient urologic procedures (panendoscopy and cystoscopy, bladder hydrodilatation, stent placement).

Patients and methods. 40 patients 18 years of age or older scheduled for short elective outpatient urological procedures with an expected duration of less than 30 minutes.

Following Institutional Review Board (IRB) approval and written informed consent, 40 American Society of Anesthesiologists (ASA) physical class 1-3 adult outpatients were enrolled and equally (n=20) randomized into remifentanil and fentanyl groups. Preoperatively, all subjects received intravenous (IV) midazolam 1-2 mg and were induced with propofol 2 mg/kg IV. Muscle relaxation was achieved with succinylcholine or rocuronium, followed by intubation. The remifentanil group received remifentanil 1 g/kg IV at induction with a maintenance dose of remifentanil 0.1 to 2 g/kg/min IV in the presence of 60% nitrous oxide (N2O)/40% oxygen (O2) and end-tidal isoflurane of 0.3 to 0.4% (for amnesia). The fentanyl group received fentanyl 2 g/kg IV at induction, maintenance dose of fentanyl 2 to 3 g/kg IV intermittent bolus, and 60% N2O/40% O2 with 2% end-tidal isoflurane. Muscle relaxation was reversed at the end of anesthesia as needed. Times for OR entry, emergence, extubation, total OR time (entry to exit) and PACU discharge time, as well as Aldrete scores at time of OR exit and PACU discharge were determined. Data was evaluated by ANOVA, t-test and Mann-Whitney tests. A p<0.05 value was considered statistically significant.

Results. There was no significant difference between groups in age, gender, weight, ASA class, PACU analgesic or antiemetic use, or times of emergence, extubation, OR exit and PACU discharge. There was a significant difference (p<0.05) in OR exit Aldrete score but not PACU discharge Aldrete score. No adverse events were noted.

Conclusions. While there was no difference between the remifentanil and fentanyl groups regarding recovery time from OR and PACU, remifentanil patients had significantly better OR exit Aldrete scores with less sedation upon arrival at phase I PACU recovery than the fentanyl group. This anesthesia technique may prove helpful for fast-track eligibility of these patients.

Key words: remifentanil, fentanyl, isoflurane, general anesthesia, urologic procedures, outpatient surgery, Aldrete score, recovery time, discharge time

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Aerosolized colistin in the treatment of multiresistant Pseudomonas aeruginosa nosocomial pneumonia (Views : 9378 times)

Abstract

Introduction. Multiresistant Pseudomonas aeruginosa (MRPA) nosocomial pneumonia is a significant cause of mortality and morbidity in the ICU. We report our experience with aerosolized colistin in the treatment of MRPA nosocomial pneumonia.

Patients and methods. It is a prospective, observational study performed over 2 years (2006-2007). Patients who developed MRPA nosocomial pneumonia and were treated with aerosolized colistin were included. The criteria used to assess if treatment was successful were extubation and ICU mortality rates.

Results. We report 32 patients of whom 12 were women and 20 men. The mean age was 48 ± 19 years. All patients were receiving mechanical ventilation. The mean length of ventilation was 22 ± 5.5 days. The bronchial sampling technique used was broncho-alveolar lavage. The mean delay of infection (duration between intubation and pneumonia diagnosis) was 7 ± 2 days. Isolated MRPA was susceptible only to colistin. The treatment was aerosolized colistin for all patients (4 MUI/day). A positive blood culture (n=5) was a prerequisite for administering colistin intravenously (4 MUI/day). Any potential toxicity was observed. The mean delay of extubation after starting treatment was 10 days. Sterile samples were obtained on average by the eighth day. No deaths were recorded.

Conclusion. It seems that aerosolized colistin is an important alternative to treat MRPA nosocomial pneumonia in ICU. Our results need further confirmation by other multicentre studies.

Keywords: multi-resistant Pseudomonas aeruginosa, colistin, nebulization, ICU

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A rare cause of intestinal obstruction due to an exophytic gastrointestinal stromal tumor of the small bowel (Views : 5646 times)

Abstract

Introduction: Gastrointestinal stromal tumors constitute a distinct group of rare gastrointestinal tract tumors that originate from the interstitial cells of Cajal. These jejunoileal lesions are a rare cause of obstruction but can be associated with substantial morbidity.

Case: A 59-year-old woman presented to the emergency department with abdominal pain and distention. Physical examination revealed tenderness and rebound in right lower quadrant. Computed tomography revealed a mass in lower right quadrant. A 9x9x4 cm exophytic ileal mass was observed at exploration. Preoperative diagnose was a small bowel tumor and then segmental resection and primary anastomosis were performed. Histopathological investigation revealed spindle cells that stained strongly for C-117, consistent with a diagnosis of a malign gastrointestinal stromal tumor.

Conclusion: We conclude that exophytic small bowel gastrointestinal stromal tumors are rare lesions, which should be kept in mind by physicians among the diagnosis of small bowel obstructions in order to reduce substantial morbidity and mortality.

Key words: intestinal obstruction, gastrointestinal stromal tumor, small bowel, surgery

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