Severe ARDS may cause right heart failure with extreme hepatomegaly but without hepatic failure.

A young trauma patient developed severe adult respiratory distress syndrome (ARDS), right heart failure, hepatic congestion and an extreme hepatomegaly but no hepatic failure. The patient needed 100% oxygen during ventilatory support for 80 days and was weaned from the ventilator after more than 100 days. The hepatomegaly gradually disappeared. Four months after the injury, the anatomical shape of the lungs, heart and liver were normalized. This case illustrates that severe ARDS may cause right heart failure and extreme hepatomegaly due to venous congestion in the liver and spleen, but without hepatic failure.

Autocycling and increase in intrinsic positive end-expiratory pressure during mechanical ventilation.

Modern ventilators are complicated electronic instruments with microprocessors and software, with the possibility of technical errors and problems such as autocycling. Despite autocycling being recognized as a problem in textbooks and reviews, there are few reports about autocycling in the literature. We report a case where a sudden increase in respiratory frequency due to autocycling resulted in a dangerous increase in intrinsic positive end-expiratory pressure (intrinsic PEEP, PEEPi). We think our case illustrates that autocycling does occur, but that the exact underlying mechanism may be hard to document and understand for clinicians. To remedy this situation, we suggest that manufacture-independent technical expertise should be established to evaluate incidents and suggest improvements.

Acute epiglottitis in a rural area: experiences with an anesthesiologist-staffed ambulance helicopter.

The majority of fatalities due to acute epiglottitis (AE) result from prehospital airway problems. We reviewed the courses of 14 patients with AE treated by an aeromedical team consisting of an anesthesiologist and a paramedic. Eight patients were transported from a physician's office or from the patient's own home. One patient was intubated at the scene, and two received ventilatory support with mask and bag en route to the hospital. Two patients suffered cardiopulmonary arrest before arrival of the aeromedical team, both resulting in severe hypoxic encephalopathy. All six patients transported from hospitals were intubated prior to the helicopter transport. Based on our own experience and a review of the literature, we discuss prehospital airway management in this group of patients.

[Limits of intensive care]. / Avgrensinger i intensivbehandling.

The decision to withdraw or withhold life support for critically ill patients with no hope of survival is well established and widely accepted. The decision not to treat should be made by more than one doctor, and should be documented in each patient's file. Patients with a bad but not hopeless prognosis should not be weighed against other patients awaiting treatment. Relatives should be fully informed, but should not participate in the formal decision. The reasons and circumstances under which life support can be withheld or withdrawn should be examined further.

Severe anaphylactic reactions outside hospital: etiology, symptoms and treatment.

Twenty-seven patients with severe anaphylactic reactions were treated by two anesthesiologist-staffed ambulance helicopters during a 5-year period. All patients had signs of respiratory and/or circulatory failure. Cutaneous symptoms were described in 70% of the patients, gastrointestinal symptoms in 30% and central nervous symptoms in 85%. Wasp sting and drugs were the most common causes. Other etiologies were bee sting, snakebite, nuts and exercise. All patients were provided with advanced pre-hospital medical care. Epinephrine was employed in 78% of the patients. I.v. fluid therapy was started in 77%. Three patients (11%) needed endotracheal intubation. The time-span from onset of symptoms to medical attendance exceeded 45 min in two patients; both died. Of the surviving patients, 23 were hospitalized. The majority had no signs of respiratory or circulatory failure on arrival in the emergency room and needed only observation in the hospital.

The effect of positive end expiratory pressure after three types of open heart surgery.

It has previously been shown that patients who have undergone mitral valve replacement (MVR) tolerate a positive end expiratory pressure (PEEP) of 1.0 kPa better than patients who have had aortic valve replacement (AVR). the difference was explained by the fact that the mitral patients had pre-existing pulmonary vascular disease. In the present study the effect of PEEP up to 2.0 kPa is investigated in three types of operations: aortocoronary bypass graft (ACBG), mitral valve replacement, and aortic valve replacement; there were five patients in each group. We found that our mitral patients tolerated PEEP better than the two other groups, and that tolerance was not correlated to a higher pulmonary vascular resistance, but rather to a higher level of pulmonary capillary wedge pressure. The influence of PEEP varies in different types of patients and the effect is still difficult to predict.

Weaning from mechanical ventilation by means of intermittent assisted ventilation I.A.V. Case reports.

A new ventilator is described which is capable of interposing controlled breaths synchronized with the patient's own breathing rhythm. This ventilation pattern is called "intermittent assisted ventilation" (IAV). It differs from intermittent mandatory ventilation (IMV) in that each ventilator cycle is triggered by the patient. IAV constitutes a new approach to the problems during the critical period of weaning from mechanical ventilation. Further, this new ventilator provides means for continuous display and recording of airway gas flow and pressures and expired minute volume (EMV) during different types of ventilation, e.g. controlled ventilation, intermittent assisted, and spontaneous ventilation.