A survey of preferences for respiratory support in the intensive care unit for patients with acute hypoxaemic respiratory failure.

BACKGROUND: When caring for mechanically ventilated adults with acute hypoxaemic respiratory failure (AHRF), clinicians are faced with an uncertain choice between ventilator modes allowing for spontaneous breaths or ventilation fully controlled by the ventilator. The preferences of clinicians managing such patients, and what motivates their choice of ventilator mode, are largely unknown. To better understand how clinicians' preferences may impact the choice of ventilatory support for patients with AHRF, we issued a survey to an international network of intensive care unit (ICU) researchers. METHODS: We distributed an online survey with 32 broadly similar and interlinked questions on how clinicians prioritise spontaneous or controlled ventilation in invasively ventilated patients with AHRF of different severity, and which factors determine their choice. RESULTS: The survey was distributed to 1337 recipients in 12 countries. Of these, 415 (31%) completed the survey either fully (52%) or partially (48%). Most respondents were identified as medical specialists (87%) or physicians in training (11%). Modes allowing for spontaneous ventilation were considered preferable in mild AHRF, with controlled ventilation considered as progressively more important in moderate and severe AHRF. Among respondents there was strong support (90%) for a randomised clinical trial comparing spontaneous with controlled ventilation in patients with moderate AHRF. CONCLUSIONS: The responses from this international survey suggest that there is clinical equipoise for the preferred ventilator mode in patients with AHRF of moderate severity. We found strong support for a randomised trial comparing modes of ventilation in patients with moderate AHRF.

Spontaneous non-traumatic massive intraabdominal spleen bleeding in young females: Importance of ATLS principles and trauma alarm.

PATIENT: Female, 28 FINAL DIAGNOSIS: Rupture of the splenic artery aneurysm Symptoms: Hypovolemic shock Medication: - Clinical Procedure: - Specialty: Surgery. OBJECTIVE: Rare disease. BACKGROUND: ATLS principles have become a standard of care for trauma patients. However, there is poor documentation in regard to spontaneous non-traumatic life-threatening bleedings. CASE REPORT: Two women, a 21-year-old and a 28-year-old, presented to the admissions department in hemorrhagic shock. The latter woman was in her 26(th) week of pregnancy. The trauma alarm was raised and the patients received prompt, complex diagnostics including ultrasonography verifying massive intraabdominal fluid. Massive infusion therapy was initiated. The first patient was intubated in the emergency room and required cardiopulmonary rescue due to cardiopulmonary arrest. The patients were moved to the surgical theatre for life-saving operations at 30 and 60 minutes, respectively, after arrival in the emergency department. RESULTS: In the first case, we found 4 L of intraabdominal blood and a rupture in the lower pole of the splenic capsule. Splenectomy was performed. The patient developed disseminated intravascular coagulation syndrome and was transferred to a first-level trauma centre for further treatment. She survived with slight sequelae in the form of psychosocial maladjustment, and low-grade spasms and myoclonic twitches due to prolonged brain ischemia. She was steadily improving at 17 months of follow-up. Viral mononucleosis was established as the cause of the spontaneous rupture of the spleen. In the second case, we found 2.5 L of intraabdominal blood and persistent bleeding from an aneurism of the splenic artery. A splenectomy was performed. She was transferred to a first-level trauma centre for further treatment. She lost the fetus and underwent autotransplantation of the right kidney after 3 months, due to the finding of an aneurism of the right renal artery on the abdominal CT. We also found an ectasia in the ascending aorta, which will require follow-up. The patient does not have any other sequelae and has made a complete recovery at 12 months of follow-up. CONCLUSIONS: ATLS principles and trauma alarm readiness play a major role in lifesaving surgery in patients with non-traumatic hemorrhagic shock.