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COVID-19/fisiopatología , COVID-19/terapia , Presión de las Vías Aéreas Positiva Contínua/métodos , Posición Prona , Sedestación , Posición Supina , Vigilia/fisiología , Anciano , Femenino , Humanos , Italia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , SARS-CoV-2 , Resultado del TratamientoRESUMEN
Daily nursing in critical care patients may alter vital parameters, especially in the most critically ill patients. The aim of our study was to evaluate feasibility and safety of daily nursing on patients undergoing venous-venous extracorporeal membrane oxygenation (vv-ECMO) for severe respiratory failure. Daily nursing was performed following defined phases (sponge bath, elevation with scooping stretcher, change position of endotracheal tube, dressing replacement). We recorded physiological and ECMO parameters before and during daily nursing in 5 patients for several days (total: 25 daily nursing) and adverse events: desaturation, hypertension, reduction of mixed venous oxygen saturation, arterial oxygen saturation or ECMO blood flow and elevation in minute ventilation. Sedative drug dosage and additional bolus were recorded. Daily nursing was performed in 92 % of cases (23/25), with a minimum of two adverse events per daily nursing. Hypertension and tachycardia were mostly recorded at the beginning, while desaturation, reduction in mixed venous oxygen saturation and blood flow were recorded during elevation with scooping stretcher. Increase in minute ventilation was frequent in spontaneous breathing patients. Additional bolus of sedation was required before and/or during nursing. Daily nursing significantly alters physiologic parameters; thus, it should be performed only when physicians are readily available to treat adverse events.
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Cuidados Críticos , Oxigenación por Membrana Extracorpórea/enfermería , Insuficiencia Respiratoria/terapia , Adulto , Sedación Consciente , Estudios de Factibilidad , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Intercambio Gaseoso PulmonarRESUMEN
INTRODUCTION: Sepsis, a leading cause of death in critically ill patients, is the result of complex interactions between the infecting microorganisms and the host responses that influence clinical outcomes. We evaluated the prognostic value of presepsin (sCD14-ST), a novel biomarker of bacterial infection, and compared it with procalcitonin (PCT). METHODS: This is a retrospective, case-control study of a multicenter, randomized clinical trial enrolling patients with severe sepsis or septic shock in ICUs in Italy. We selected 50 survivors and 50 non-survivors at ICU discharge, matched for age, sex and time from sepsis diagnosis to enrollment. Plasma samples were collected 1, 2 and 7 days after enrollment to assay presepsin and PCT. Outcome was assessed 28 and 90 days after enrollment. RESULTS: Early presepsin (day 1) was higher in decedents (2,269 pg/ml, median (Q1 to Q3), 1,171 to 4,300 pg/ml) than in survivors (1,184 pg/ml (median, 875 to 2,113); P = 0.002), whereas PCT was not different (18.5 µg/L (median 3.4 to 45.2) and 10.8 µg/L (2.7 to 41.9); P = 0.31). The evolution of presepsin levels over time was significantly different in survivors compared to decedents (P for time-survival interaction = 0.03), whereas PCT decreased similarly in the two groups (P = 0.13). Presepsin was the only variable independently associated with ICU and 28-day mortality in Cox models adjusted for clinical characteristics. It showed better prognostic accuracy than PCT in the range of Sequential Organ Failure Assessment score (area under the curve (AUC) from 0.64 to 0.75 vs. AUC 0.53 to 0.65). CONCLUSIONS: In this multicenter clinical trial, we provide the first evidence that presepsin measurements may have useful prognostic information for patients with severe sepsis or septic shock. These preliminary findings suggest that presepsin may be of clinical importance for early risk stratification.
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Calcitonina/sangre , Receptores de Lipopolisacáridos/sangre , Fragmentos de Péptidos/sangre , Precursores de Proteínas/sangre , Sepsis/sangre , Sepsis/diagnóstico , Albúmina Sérica/metabolismo , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Péptido Relacionado con Gen de Calcitonina , Estudios de Casos y Controles , Femenino , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Mortalidad/tendencias , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sepsis/mortalidad , Resultado del TratamientoRESUMEN
BACKGROUND: Major thoracic trauma represents a life-threatening condition, requiring a prompt multidisciplinary approach and appropriate pathways for effective recovery. While acute morbidity and mortality are well-known outcomes in thoracic-traumatized patients, long-term quality of life in patients surviving surgical treatment has not been widely investigated before. METHODS: Between November 2016 and November 2023, thirty-two consecutive patients were operated on because of thoracic trauma. Age, sex, comorbidities, location and extent of thoracic trauma, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), Organ Injury Scale (OIS), intra and extrathoracic organ involvement, mechanism of injury, type of surgical procedure, postoperative complications, ICU and total length of stay, immediate clinical outcomes and long-term quality of life-by using the EQ-5D-3L scale and Numeric Rate Pain Score (NPRS)-were collected for each patient Results: Results indicated no significant difference in EQOL.5D3L among patients with thoracic trauma based on AIS (p = 0.55), but a significant difference was observed in relation to ISS (p = 0.000011). CONCLUSIONS: ISS is correlated with the EQOL.5D3L questionnaire on long-term quality of life, representing the best prognostic factor-in terms of long-term quality of life-in patients surviving major thoracic trauma surgical treatment.
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Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional angiography) within 6 h of hospital admission. Additionally, our goal was to develop a prehospital triage tool capable of estimating the likelihood of requiring an emergent procedure following hospital admission. We conducted a retrospective observational study, analyzing both prehospital and in-hospital data obtained from the Lombardy Trauma Registry. We conducted a multivariable logistic regression analysis to identify independent predictors of emergency procedures within the first 6 h from admission. Subsequently, we developed and internally validated a triage score composed of factors associated with the probability of requiring an emergency procedure. The study included a total of 3985 patients, among whom 295 (7.4%) required an emergent procedure within 6 h. Age, penetrating injury, downfall, cardiac arrest, poor neurological status, endotracheal intubation, systolic pressure, diastolic pressure, shock index, respiratory rate and tachycardia were identified as predictors of requiring an emergency procedure. A triage score generated from these predictors showed a good predictive power (AUC of the ROC curve: 0.81) to identify patients requiring an emergent surgical or non-surgical procedure within 6 h from hospital admission. The proposed triage score might contribute to predicting the need for immediate resource availability in trauma patients.
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PURPOSE OF REVIEW: To describe a physiopathological-based approach to clinical management of severely hypoxemic patients that integrates the most recent findings on the use of rescue therapies. RECENT FINDINGS: Several techniques are available to improve oxygenation in severely hypoxemic patients. Survival benefits have not been proved for most of these techniques. In a recent randomized trial, centralization of acute respiratory distress syndrome patients to a specialized center able to provide extracorporeal membrane oxygenation showed better survival as compared to conventional treatment. Randomized trials failed to prove survival benefits with the use of high levels of positive end-expiratory pressure (PEEP) or prone positioning. However, pooled data from two meta-analyses showed significant higher survival in the most severe patients both with the use of higher PEEP and prone positioning. SUMMARY: Treatment of severely hypoxemic patients should aim to improve oxygenation while limiting ventilator-induced lung injury. A physiopathological approach that accounts for the underlying mechanisms of hypoxemia, and physiological and clinical effects of different treatments is likely the best guide we have to treat severely hypoxemic patients.
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Hipoxia/terapia , Índice de Severidad de la Enfermedad , Oxigenación por Membrana Extracorpórea , Humanos , Hipoxia/etiología , Hipoxia/fisiopatología , Respiración con Presión Positiva , Posición Prona/fisiología , Síndrome de Dificultad Respiratoria , SobrevidaRESUMEN
OBJECTIVE: To assess the behavior of different helmets after discontinuation of fresh gas flow by disconnection at the helmet inlet, flow generator, or gas source. DESIGN AND SETTING: Randomized physiological study in a university research laboratory. PATIENTS: Five healthy volunteers. INTERVENTION: CPAP (FIO2 50%, PEEP 5 cmH2O) delivered in random sequence with three different helmets: 4Vent (Rüsch), PN500 (Harol), CaStar (StarMed) with antisuffocation valve open or locked. For each helmet all three disconnections were randomly employed up to 4 min. MEASUREMENTS AND RESULTS: During flow disconnection we measured: respiratory rate and tidal volume by respitrace; inspiratory and expiratory CO2 concentration, and FIO2 from a nostril; SpO2 by pulse oxymetry. Independently of the site of disconnection we observed a fast increase in CO2 rebreathing and minute ventilation, associated with a decrease in inspired O2 concentration. In the absence of an operational safety valve, larger helmet size and lower resistance of the inlet hose resulted in slower increase in CO2 rebreathing. The presence of the safety valve limited the rebreathing of CO2, and the increase in minute ventilation but did not protect from a decrease in FIO2 and loss of PEEP. CONCLUSIONS: While the use of a safety valve proved effective in limiting CO2 rebreathing, it did not protect from the risk of hypoxia related to decrease in FIO2 and loss of PEEP. In addition to a safety antisuffocation valve, a dedicated monitoring and alarming systems are needed to employ helmet CPAP safely.
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Presión de las Vías Aéreas Positiva Contínua/instrumentación , Adulto , Diseño de Equipo , Falla de Equipo , Humanos , MasculinoRESUMEN
PURPOSE: Prone positioning (PP) improves oxygenation and outcome of patients with acute respiratory distress syndrome undergoing invasive ventilation. We evaluated feasibility and efficacy of PP in awake, non-intubated, spontaneously breathing patients with hypoxemic acute respiratory failure (ARF). MATERIAL AND METHODS: We retrospectively studied non-intubated subjects with hypoxemic ARF treated with PP from January 2009 to December 2014. Data were extracted from medical records. Arterial blood gas analyses, respiratory rate, and hemodynamics were retrieved 1 to 2 hours before pronation (step PRE), during PP (step PRONE), and 6 to 8 hours after resupination (step POST). RESULTS: Fifteen non-intubated ARF patients underwent 43 PP procedures. Nine subjects were immunocompromised. Twelve subjects were discharged from hospital, while 3 died. Only 2 maneuvers were interrupted, owing to patient intolerance. No complications were documented. PP did not alter respiratory rate or hemodynamics. In the subset of procedures during which the same positive end expiratory pressure and Fio2 were utilized throughout the pronation cycle (n=18), PP improved oxygenation (Pao2/Fio2 124±50 mmHg, 187±72 mmHg, and 140±61 mmHg, during PRE, PRONE, and POST steps, respectively, P<.001), while pH and Paco2 were unchanged. CONCLUSIONS: PP was feasible and improved oxygenation in non-intubated, spontaneously breathing patients with ARF.
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Oxígeno/fisiología , Respiración con Presión Positiva/métodos , Posición Prona , Síndrome de Dificultad Respiratoria/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Análisis de los Gases de la Sangre , Femenino , Hemodinámica , Humanos , Huésped Inmunocomprometido , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Insuficiencia Respiratoria/complicaciones , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
PURPOSE: To investigate the effect of a wide range of assistance levels during neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV) on respiratory pattern, breathing variability, and incidence of tidal volumes (V (T)) above 8 and 10 ml/kg in acute respiratory failure patients. METHODS: Eight increasing NAVA levels (0.5, 1, 1.5, 2, 2.5, 3, 4, and 5 cmH(2)O/µV) and four increasing pressure support (PSV) levels (4, 8, 12, and 16 cmH(2)O) were applied to obtain 10 min of stable recordings in 15 patients. RESULTS: One out of 15 patients did not sustain the NAVA levels of 3, 4, and 5 cmH(2)O/µV and was excluded. The 5 cmH(2)O/µV NAVA level was not tolerated by three patients and it was excluded. Increasing NAVA levels were associated with decreased diaphragm electrical activity (EAdi), and, at variance with PSV, with small changes in V (T), no changes in respiratory rate (RR), and increases in V (T) and EAdi variability. At high NAVA levels, an increase in V (T) variability was associated with increased incidence of V (T) above 8 and 10 ml/kg and an uncomfortable respiratory pattern in some patients. CONCLUSIONS: Increasing NAVA levels were associated with no effect on RR, small increase in V (T), and increase in V (T) and EAdi variability. Effective decrease in EAdi occurred at NAVA levels below 2-2.5 cmH(2)O/µV, while preserving respiratory variability and low risks of V (T) above 8 or 10 ml/kg.
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Soporte Ventilatorio Interactivo , Síndrome de Dificultad Respiratoria/fisiopatología , Síndrome de Dificultad Respiratoria/terapia , Frecuencia Respiratoria , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Soporte Ventilatorio Interactivo/métodos , Masculino , Persona de Mediana EdadRESUMEN
We report a case of severe posttraumatic acute respiratory distress syndrome (ARDS) complicated by bronchopleural fistulae (BPF). The stiff ARDS lung and huge air leaks from BPF resulted in the failure of different protective mechanical ventilation strategies to provide viable gas exchange. Lung rest, achieved by extracorporeal carbon dioxide removal (ECCO2R), allowed weaning from mechanical ventilation, closure of BPF, and resumption of spontaneous breathing.
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Fístula Bronquial/patología , Oxigenación por Membrana Extracorpórea/métodos , Síndrome de Dificultad Respiratoria/terapia , Accidentes de Tránsito , Adulto , Fístula Bronquial/complicaciones , Dióxido de Carbono/metabolismo , Humanos , Pulmón/fisiopatología , Masculino , Respiración , Respiración ArtificialRESUMEN
PURPOSE: Standard polyvinylchloride (PVC) endotracheal tube (ETT) cuffs do not protect from aspiration across the cuff, a leading cause of ventilator-associated pneumonia (VAP). In a long-lasting in vitro study we compared the effect of different cuff materials (PVC, polyurethane, and guayule latex), shapes (cylindrical, conical), and positive end expiratory pressures (PEEP) in reducing fluid leakage across the cuff. METHODS: We compared fluid leakage across a cylindrical double-layer guayule latex prototype cuff, three cylindrical PVC cuffs (Mallinckrodt Hi-Lo, Mallinckrodt HighContour, Portex Ivory), one conical PVC cuff (Mallinckrodt TaperGuard), and two polyurethane cuffs (Mallinckrodt SealGuard, conical; Microcuff, cylindrical). Ten centimeters of dyed water was poured above the cuffs inflated (pressure 30 cmH(2)O) in a vertical cylinder (diameter 20 mm). A respiratory circuit connected the bottom of the cylinder to a breathing bag inflated at four pressures (PEEP = 0, 5, 10, 15 cmH(2)O). Pictures were taken every 60 s for 24 h to measure leakage as a reduction in the water column above the cuff. Five new ETTs of each type were tested. RESULTS: The guayule latex cuffs showed no leakage at all the PEEP levels. Both the cylindrical and conical polyurethane cuffs showed limited leakage (2.1 ± 1.8 cm of water) only for PEEP zero. The PVC cuffs showed reduced leakage with increasing PEEP: 8.4 ± 1.5, 7.8 ± 2.2, 2.2 ± 1.0, and 0 cm of water at 0, 5, 10, and 15 cmH(2)O, respectively. Among all the PVC cuffs, the conical shape ensured higher sealing properties. CONCLUSIONS: The guayule latex cuffs always prevented fluid leakage; the polyurethane and PVC cuffs required incremental levels of PEEP to prevent fluid leakage ever-present at zero PEEP.
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Falla de Equipo , Intubación Intratraqueal/instrumentación , Diseño de Equipo , Humanos , Plásticos , Respiración con Presión PositivaRESUMEN
INTRODUCTION: Severe mixed ß-blocker and calcium channel blocker intoxication presents a significant risk for patient mortality. Although treatment is well-established, it sporadically fails to support the patient through massive overdoses, thus requiring non-conventional treatments. We report the use of extra-corporeal life support in a patient with refractory hemodynamic impairment due to multi-drug intoxication. Although sometimes used in clinical practice, extra-corporeal membrane oxygenation for intoxications has rarely been reported. CASE PRESENTATION: A 36-year-old Caucasian man presented to our hospital with refractory hypotension, severe cardiac insufficiency and multi-organ failure due to mixed intoxication with atenolol, nifedipine, Lacidipine and sertraline. Together with standard treatment, we performed extra-corporeal membrane oxygenation to overcome refractory cardiogenic shock and lead the patient to achieve a full recovery. CONCLUSION: Standard of care for ß-blocker and calcium channel blocker intoxication is well-defined and condensed into protocols of treatment. Although aimed at clearing the noxious agents from the patient's system, standard measures may fail to provide adequate hemodynamic support to allow recovery. In selected cases, extra-corporeal membrane oxygenation could be considered a bridge to drug clearance while preventing multi-organ failure due to profound shock.
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PURPOSE: Transfer of severely hypoxic patients is a high-risk procedure. Extracorporeal membrane oxygenation (ECMO) allows safe transport of these patients to tertiary care institutions. Our ECMO transportation program was instituted in 2004; here we report results after 5 years of activity. METHODS: This is a clinical observational study. Criteria for ECMO center activation were: potentially reversibile respiratory failure, PaO2 <50 mmHg with FiO2 >0.6 for >12 hours, PEEP >5 cmH20, Lung Injury Score (LIS) ≥3 or respiratory acidosis with pH <7.2, no intracranial bleeding, and no absolute contraindication to anticoagulation. If eligible, a skilled crew applied ECMO at the referral hospital. Transportation was performed with a specially equipped ambulance. RESULTS: Sixteen patients were possible candidates for ECMO transfer. Two patients were excluded while 14 (mean±SD, age 35.4±18.6, SOFA 8.4±3.7, Oxygenation Index 43.7±13.4) were transported to our institution (distance covered 102±114 km, global duration of transport 589±186 minutes). Two patients improved after iNO-trial and were transferred and subsequently managed without ECMO. The remaining 12 patients were transferred on veno-venous ECMO with extracorporeal blood flow 2.7±1 L·min⻹, gas flow 3.8±1.8 L·min⻹, and FiO2 1. Data were recorded 30 minutes before and 60 minutes after initiation of ECMO. ECMO improved PCO2 (75±23 vs. 53±9 mmHg, p<0.01) thus improving pH (7.28±0.13 vs. 7.39±0.05, p<0.01) and allowing a reduction in respiratory rate (35±14 vs. 10±4 breaths/min, p<0.01), minute ventilation (10.1±3.8 vs. 3.7±1.7 L·min⻹, p<0.01), and mean airway pressure (26±6.5 vs. 22±5 cmH2O, p<0.01). No major clinical or technical complications were observed. CONCLUSIONS: ECMO effectively enabled high-risk ground transfer of severely hypoxic patients.
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Ambulancias , Oxigenación por Membrana Extracorpórea , Hipoxia/terapia , Transferencia de Pacientes , Síndrome de Dificultad Respiratoria/terapia , Adulto , Anciano , Preescolar , Diseño de Equipo , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/instrumentación , Femenino , Hospitales Generales , Humanos , Hipoxia/diagnóstico , Hipoxia/fisiopatología , Italia , Pulmón/fisiopatología , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Derivación y Consulta , Síndrome de Dificultad Respiratoria/diagnóstico , Síndrome de Dificultad Respiratoria/fisiopatología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: We assessed the performance of different continuous positive airway pressure (CPAP) helmets equipped with a safety valve during discontinuation of fresh gas flow. METHODS: This was a physiological study of five healthy volunteers. We delivered CPAP (fresh gas flow 60 l/min, FiO(2) 60%, PEEP 5 cmH(2)O) with three different helmets in a random sequence: 4Vent (Rüsch), HelmHAR-cp (Harol) and CaStar CP210 (StarMed). For each helmet we randomly applied, for up to 4 min, three disconnections of fresh gas flow: helmet inlet (D(inlet)), flowmeter (D(flowmeter)) and gas source (D(source)). We continuously recorded from a nostril: end-tidal CO(2) (PetCO(2)), inspiratory CO(2) (PiCO(2)), fraction of inspired oxygen (FiO(2)) and respiratory rate (RR). RESULTS: During every disconnection we observed an increase in PiCO(2) and PetCO(2) with a drop in FiO(2), while RR did not change. FiO(2) decreased more quickly in the CaStar, equipped with the largest safety valve, during D(source) and D(flowmeter), while FiO(2) decreased more quickly during D(inlet) in CaStar and in 4Vent. PiCO(2) resulted in a lower increase in CaStar during D(source) and D(flowmeter) compared to 4Vent. PetCO(2) in CaStar increases more slowly compared to 4Vent during D(source) and more slowly compared to the other two helmets during D(flowmeter). During D(inlet) similar degrees of CO(2) rebreathing and PetCO(2) were recorded among all the helmets. CONCLUSIONS: To minimize CO(2) rebreathing during disconnection of the fresh gas supply while performing helmet CPAP, it is desirable to utilize large helmets with a large anti-suffocation valve. Monitoring and alarm systems should be employed for safe application of helmet CPAP.
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Presión de las Vías Aéreas Positiva Contínua/instrumentación , Falla de Equipo , Seguridad de Equipos , Dispositivos de Protección Respiratoria/normas , Adulto , Dióxido de Carbono/análisis , Femenino , Humanos , Masculino , Oxígeno/administración & dosificación , Adulto JovenRESUMEN
PURPOSE: Vascular access and cannulation are crucial issues to maximize the efficiency of extracorporeal circulation techniques and to preserve patients' safety. Techniques of cannulation have changed over the years, from surgical cutdown to percutaneous approaches, which are now considered standard practice. We describe an original modified percutaneous cannulation technique developed in our Department and we report our clinical experience and complications observed. METHODS: A Seldinger technique utilizing 3 guidewires with passage of a dilator over each guidewire was used. Two concentric pursestring sutures, prepared before cannulation, minimize procedure-associated bleeding. Cannulation is performed under direct fluoroscopic control. RESULTS: From 1997 to 2009, 38 patients (31 VV-ECLS, 7 VA-ECLS) have been cannulated using our technique, resulting in a total of 69 venous cannulations. Average external caliber of venous cannulae was 23 Fr (15-29 Fr). Mean duration of the entire cannulation procedure was 40 minutes (20-60 min). Adverse events occurred in 3 patients. CONCLUSIONS: The technique described is safe and feasible and the incidence of procedure-related complications is very low, but it may require longer time to be performed.
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Cateterismo Venoso Central , Circulación Extracorporea/métodos , Cateterismo Venoso Central/efectos adversos , Cateterismo Venoso Central/instrumentación , Catéteres de Permanencia , Circulación Extracorporea/efectos adversos , Circulación Extracorporea/instrumentación , Humanos , Radiografía Intervencional , Técnicas de Sutura , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: We investigated the effects of periodical high pressure breaths (SIGH) or biphasic positive pressure ventilation (BIPAP) during helmet continuous positive airway pressure (CPAP) in patients with acute hypoxic respiratory failure. METHODS: We used a recently developed electromechanical expiratory valve (TwinPAP, StarMed, Mirandola, Italy), which is time-cycled between two customizable positive end-expiratory pressure (PEEP) levels. We studied 21 patients (67 ± 17 years old) undergoing helmet CPAP. Continuous flow CPAP system was set at 60 l/min flow rate while maintaining clinical FiO(2) (51 ± 15%). Five steps, lasting 1 h each, were applied: (1) spontaneous breathing with PEEP 0 cmH(2)O (SB), (2) CPAP with PEEP 8 cmH(2)O (CPAP(basal)), (3) low PEEP, 8 cmH(2)O, for 25 s and high PEEP, 25 cmH(2)O, for 5 s (SIGH), (4) low PEEP, 8 cmH(2)O, for 3 s and high PEEP, 20 cmH(2)O, for 3 s (BIPAP), (5) CPAP with PEEP 8 cmH(2)O (CPAP(final)). We randomized the sequence of SIGH and BIPAP. RESULTS: PaO(2) was significantly higher during all steps compared to SB. When compared to CPAP(basal), both SIGH and BIPAP induced a further increase in PaO(2). PaO(2) during SIGH and BIPAP were not different. The oxygenation improvement was maintained during CPAP(final). CONCLUSIONS: Superimposed, nonsynchronized positive pressure breaths delivered during helmet CPAP by means of the TwinPAP system may improve oxygenation in patients with acute hypoxemic respiratory failure, even at a rate as low as two breaths per minute.
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Presión de las Vías Aéreas Positiva Contínua/instrumentación , Hipoxia/terapia , Oxígeno/metabolismo , Insuficiencia Respiratoria/terapia , Anciano , Femenino , Humanos , Hipoxia/fisiopatología , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Insuficiencia Respiratoria/fisiopatologíaRESUMEN
PURPOSE: Assessing feasibility and physiological effects of sedation with sevoflurane, administered with the anesthetic conserving device (AnaConDa), in comparison with propofol and remifentanil. METHODS: Seventeen patients undergoing mechanical ventilation underwent sedation with sevoflurane delivered with AnaConDa (phase SevAn), preceded and followed by sedation with propofol and remifentanil (phases ProRe(1), ProRe(2)), with the same sedation targets. RESULTS: With both strategies it was possible to achieve the sedation targets. Time required to sedate and awake patients was greater during SevAn than ProRe(1): respectively, 3.3 +/- 3.0 versus 8.9 +/- 6.1 and 7.47 +/- 5.05 versus 16.3 +/- 11.4 min. During SevAn the PaCO(2) and minute ventilation increased. Hemodynamics was stable between ProRe(1) and SevAn, except for an increase in heart rate in the SevAn phase. Environmental pollution from sevoflurane was within the safety limits. CONCLUSIONS: Sevoflurane can be effectively and safely used for short-term sedation of ICU patients with stable hemodynamic conditions.
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Anestesiología/instrumentación , Anestésicos por Inhalación/farmacología , Enfermedad Crítica , Sedación Profunda/métodos , Éteres Metílicos/farmacología , Administración por Inhalación , Anciano , Anestésicos por Inhalación/administración & dosificación , Estudios Cruzados , Estudios de Factibilidad , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Éteres Metílicos/administración & dosificación , Persona de Mediana Edad , Estudios Prospectivos , SevofluranoRESUMEN
PURPOSE: Extracorporeal CO2 removal is an effective procedure to allow a protective ventilatory strategy in ARDS patients, but it is technically challenging due to the high blood flow required. Increasing the CO2 transfer through the membrane lung (ML) may lower the demand of extracorporeal blood flow and consequently allow for a wider clinical application of this technique. Since only the dissolved CO2 (5% of the total CO2 content) is easily removed by the ML, we tested whether acidifying the blood entering the ML to convert bicarbonate ions towards dissolved CO2 could enhance the CO2 transfer though the ML. METHODS: Six pigs were connected to an extracorporeal circuit comprising a ML. The extracorporeal blood flow was 500 ml/min, while the gas flow was 10 l/min. A 15-min continuous infusion of 0.5 N lactic acid was added to the extracorporeal blood flow before the ML at a rate of 1, 2 and 5 mEq/min. Between steps we waited for a reequilibration time of at least 30 min. RESULTS: Acid infusion at 0, 1, 2 and 5 mEq/min increased pCO2 (56.19 +/- 7.92, 68.24 +/- 11.73, 84.28 +/- 11.17 and 136.66 +/- 18.46 mmHg, respectively) and decreased pH (7.39 +/- 0.05, 7.30 +/- 0.05, 7.20 +/- 0.05 and 6.91 +/- 0.05, respectively). ML CO2 removal increased 11, 23 and 70% during acid infusion at 1, 2 and 5 mEq/min, respectively. CONCLUSIONS: Blood acidification at the inlet of a ML with infusion of 1, 2 and 5 mEq/min of lactic acid can increase the CO2 removal capacity of the ML up to 70%.