Treatment of oilfield produced water by waste stabilization ponds: biodegradation of petroleum-derived materials.

This study evaluated the biological treatability of produced water (PW), the water separated from oil at the wellhead which contains both dispersed oil and low levels of heavy metals, using waste stabilisation ponds (WSPs). We examined both chemical oxygen demand (COD) and oil and grease (O&G) removal using different process configurations (hydraulic retention time (HRT), aerobic and anaerobic conditions, oil skimming, effluent recycle) in a small (10 L) reactor being fed a synthetic PW (COD=1050-1350 mg L(-1), O&G=400-500 microL L(-1), 6 g NaCl/L). The reactor was operated for 6 months, and at a HRT of 6 days (8 with evaporation) COD removals were greater than 85%, and improved over time to >90%, while O&G removals (measured with a newly developed method) were greater than 82% and also improved with time. Operating with an anaerobic section, oil skimming and 300% recycling were all found to enhance COD removal.

Treatment of oil well "produced water" by waste stabilization ponds: removal of heavy metals.

Oil well produced water (PW) can serve as an alternative water resource for restricted halotolerant agricultural purposes if the main pollutants, hydrocarbons and heavy metals, can be removed to below the irrigation standards. In this work, the potential removal of cadmium(II), chromium(III) and nickel(II) from PW by chemical precipitation in biological treatment was evaluated. Precipitation as a sulphide salt was found to be a very effective mechanism, which together with biosorption, biological metal uptake, precipitation as hydroxides and carbonates could remove heavy metals down to below irrigation standards. The existence and capability of these various mechanisms was demonstrated in the performance of a continuous artificial pond followed by intermittent sand filter, achieving removals of around 95% for nickel(II) and even higher removal rates for cadmium(II), chromium(III) from artificial PW after the installation of an anaerobic stage. The treated effluent quality was higher than that required by current European standards.

Treatment of oilfield produced water by waste stabilization ponds.

Produced water (PW) from oil wells can serve as an alternative water resource for agriculture if the main pollutants (hydrocarbons and heavy metals) can be removed to below irrigation standards. Waste stabilization ponds seem like a promising solution for PW treatment, especially in the Middle East where solar radiation is high and land is available. In this work, hydrocarbon removal from PW in a biological waste stabilization pond was examined at lab-scale followed by an intermittent slow sand filter. The system was run for 300 days and removed around 90% of the oil in the pond, and 95% after the sand filter. COD removal was about 80% in the pond effluent, and 85% after the filter. The system was tested under various operational modes and found to be stable to shock loads. Installation of oil booms and decantation of surface oil seem to be important in order to maintain good system performance over time.

A prospective trial of inhaled nitric oxide in clinical lung transplantation.

BACKGROUND: Reperfusion injury (RI) is a major cause of mortality and morbidity among lung transplant recipients. We sought to determine if prophylactic administration of inhaled nitric oxide (NO) to lung transplant recipients at reperfusion would prevent RI. We also hypothesized that if prophylactic NO proves ineffective in preventing RI then it may improve pulmonary hemodynamics and gas exchange in the subset of patients who develop RI. METHODS: After informed consent, 28 consecutive, adult lung transplant recipients received NO at 20 ppm at reperfusion. NO was withdrawn for 15 min at 6 and 12 hr after reperfusion, and gas exchange and hemodynamics were measured. RESULTS: Five of the 28 lung transplant recipients (18%) developed RI. Withdrawal of NO for 15 min in this subset of patients resulted in a significant rise in mean pulmonary artery pressure and a reduction in oxygenation index. All five patients with RI were kept on inhaled NO until full functional recovery of the allograft and were then weaned from mechanical ventilation. None required extracorporeal membrane oxygenation support; the early mortality in this group was 20% (1/5). The remaining 23 patients without RI had uneventful early postoperative course and were weaned from NO and mechanical ventilation within 36 hr of transplantation. CONCLUSIONS: Prophylactic-inhaled NO does not prevent RI in human lung transplantation. However, inhaled NO, started at reperfusion, improves gas exchange and reduces pulmonary artery pressure in those patients who develop RI.

Pulmonary toxicity of high-dose chemotherapy for breast cancer: a non-invasive approach to diagnosis and treatment.

Drug-induced pulmonary toxicity is one of the most frequent non-hematologic toxicities in breast cancer patients receiving high-dose chemotherapy with cyclophosphamide, cisplatin and BCNU (CY/CDDP/BCNU). A non-invasive clinical scoring system was utilized in an attempt to diagnose and treat early lung toxicity in 64 consecutive breast cancer patients undergoing CY/CDDP/BCNU supported by peripheral blood progenitor cells. Following hospital discharge, patients who developed symptoms suggestive of lung toxicity were evaluated with physical examination, DLCO, 2-min walking oximetry and a chest radiograph. Clinically weighted scores were assigned as follows: crackles on lung exam, 2; decrease in corrected DLCO by > 10% from baseline, 3; decrease in O2 saturation by > or = 4% with a 2-min walk, 3; and interstitial infiltrates on chest radiograph, 3. Patients with scores > or = 6 were treated with prednisone (60 mg p.o. twice a day followed by a 2-month taper). Treatment was instituted in 37 patients (58%) a median of 56 days after high-dose chemotherapy. Steroid therapy was associated with rapid clinical improvement in most patients. No fatal complications or chronic pulmonary fibrosis was seen. This non-invasive clinical scoring system can be utilized as a model for the early diagnosis of lung toxicity. Further investigation is warranted for the development of preventative measures against this syndrome.

Randomized, prospective trial of pressure-limited versus volume-controlled ventilation in severe respiratory failure.

OBJECTIVE: Volume-controlled ventilation is frequently chosen as the initial mode of ventilatory support in patients with hypoxic respiratory failure. Recent data, however, suggest that pressure-limited ventilation, using a rapidly decelerating flow delivery pattern, may produce a more desirable clinical effect through reduced peak airway pressures and increased static compliance, tissue oxygen delivery, and consumption. This study was performed to assess the feasibility and utility of early and sustained use of pressure-limited ventilation in patients with this clinical syndrome. DESIGN: Randomized, prospective trial. SETTING: Medical intensive care unit (ICU) of a university hospital. PATIENTS: The study encompassed all patients (n = 27) receiving care in a medical ICU for acute, severe hypoxic respiratory failure (PaO2/FIO2 ratio of < 150) during a 6-month period. INTERVENTIONS: Ventilatory support via either pressure-limited or volume-controlled ventilation, initiated within 24 hrs of endotracheal intubation. MEASUREMENTS: On-line monitoring of the following ten ventilatory variables at 1-min intervals for 72 hrs or until extubation or death (maximum of 43,200 data points per patient): peak airway pressure, mean airway pressure, end-tidal CO2 concentration, CO2 minute excretion, inspiratory tidal volume, expiratory tidal volume, pause pressure, end-expiratory pressure, static thoracic compliance, and inspiratory resistance. Additionally, PaO2/FIO2 values and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded on a daily basis, as were significant clinical events and changes in ventilator settings. RESULTS: Although the severity of illness at study entry as determined by APACHE II score and PaO2/FIO2 was similar in patients treated with pressure-limited or volume-controlled ventilation, peak airway pressure was consistently lower in patients randomized to pressure-limited ventilation (p = .05 at 12 hrs postintubation). The use of pressure-limited ventilation also was associated with a more rapid increase in static compliance (p = .05) than that found with volume-controlled ventilation. There was a trend toward more rapid normalization of CO2 minute excretion in patients treated with pressure-limited ventilation. Pressure-limited treated patients who survived their illness and were extubated, required fewer days of mechanical ventilation than did patients randomized to volume-controlled treated ventilation (p = .05). No pneumothoraces occurred in any study patients. One volume-controlled patient developed subcutaneous emphysema. Pressure-limited ventilation was well tolerated, and sedation requirements were equivalent in the two groups. CONCLUSIONS: Pressure-limited ventilation can be used safely and is well tolerated as an initial mode of ventilatory support in patients with acute hypoxic respiratory failure. Because the early initiation of pressure-limited ventilation is associated with lower peak airway pressure and more rapid improvement in static thoracic compliance than volume-controlled ventilation, pressure-limited ventilation may have a beneficial role when used as the primary ventilatory modality in patients with this clinical condition.

An analysis of morning report: implications for internal medicine education.

OBJECTIVE: To compare the initial diagnosis of cases presented at morning report with the final morning report diagnosis reached at discharge from the Medicine service and the diagnosis as evaluated 6 months after discharge. DESIGN: Prospective cohort study of morning report cases. SETTING: A university internal medicine residency program. MEASUREMENTS: Proportion of morning report cases in which the initial morning report diagnosis differed from the final morning report diagnosis at discharge or, in cases where a firm diagnosis was not reached at discharge, the proportion for which a diagnosis was established by 6 months after discharge. MAIN RESULTS: In 24% of cases, a firm morning report diagnosis was not available at discharge. For 61% of these, a diagnosis could be established by 6-month follow-up: for 36% the diagnosis differed from the final morning report diagnosis; and for 25% it was the same. Among cases where a firm final diagnosis was reached during morning report, the initial morning report diagnosis differed for 17%. CONCLUSIONS: Most patients discharged without a firm diagnosis have one established by 6 months later--often with surprising results. Postdischarge follow-up information could enhance the educational value of inpatient cases.