Noninvasive face mask ventilation in patients with acute respiratory failure.

Noninvasive face mask ventilation has been used successfully in patients with paralytic respiratory failure. This study evaluated whether noninvasive face mask ventilation can be used for patients with acute respiratory failure due to intrinsic lung disease. Six patients with hypercapnia and four with hypoxemic acute respiratory failure met clinical and objective criteria for mechanical ventilation, which was delivered with pressure control and pressure support via a tightly strapped, clear face mask. No patient terminated the study because of inability to deliver adequate ventilation or to improve oxygen exchange; three eventually required endotracheal intubation. The mask was generally well tolerated. All patients had a nasogastric tube placed on suction, and none vomited or aspirated. The mean duration of treatment was 33 h (range, 3 to 88). The physiologic response was considered similar to that which would have been achieved with conventionally delivered ventilation. Noninvasive face mask ventilation may have a role in managing respiratory failure.

Bronchoalveolar lavage plasmacytosis in a patient with a plasma cell dyscrasia.

A patient with serum monoclonal gammopathy, Bence-Jones proteinuria, and bone marrow plasmacytosis underwent fiberoptic bronchoscopic study for evaluation of interstitial lung disease. Bronchoalveolar lavage fluid contained 47 percent plasma cells, which were monoclonal by immunoperoxidase staining. This is the first time BAL plasmacytosis has been demonstrated in a patient with a plasma cell dyscrasia.

Hyperthermia, rhabdomyolysis, and myoglobinuric renal failure after recreational use of cocaine.

A patient had hyperthermia, rhabdomyolysis, and myoglobinuric renal failure after the recreational use of cocaine. We attribute this to the pyrogenic properties of cocaine and environmental factors. The use of cocaine during summer months or in areas with high ambient temperatures should alert physicians to the development of hyperthermia with or without seizures. Prompt recognition of the ensuing complications including mixed metabolic acidosis, rhabdomyolysis, and renal failure can result in appropriate and effective treatment.

Gastrointestinal complications in critically ill patients: the intensivists' overview.

The critical care environment may be characterized by invasive monitoring, vasoactive drugs, and major interventions which may have adverse effects on gastrointestinal function. Furthermore, conditions such as heart failure or sepsis may compromise oxygen delivery to gastrointestinal organs. Life threatening illness from a variety of causes may produce endoscopically evident gastritis or ulceration in up to 100% of patients, and clinically evident bleeding in 20%. Clinical studies suggest that antacids or H2 receptor blockers may reduce the frequency of this complication. Other conditions are associated with a spectrum of hepatic dysfunction ranging from the cholestatic jaundice of reactive hepatopathy during sepsis to centrilobular necrosis and hepatitis of shock liver. Additionally, many drugs used in the critical care setting may adversely affect mesenteric oxygen delivery and result in ischemia or infarction of the bowel. An increased awareness and understanding of these and other gastrointestinal complications in critically ill patients will, it is hoped, lead to earlier detection and better therapy than is now available.

Acquired renal insufficiency in critically ill patients.

We undertook a study to determine the frequency, predisposing factors, and outcome in 315 patients admitted to a medical-surgical ICU, of whom 47 (14.9%) subsequently acquired renal insufficiency (ARI) during their stay in the unit. Four well-recognized risk factors for ARI were present alone or in combination in all episodes: hypotension, sepsis, aminoglycoside antibiotics, and radiocontrast dye. Hypotension was the most prevalent factor, present in 42 (85.8%) episodes, and was the sole factor present in 18 (36.7%). Patients with ARI but without hypotension all survived their ICU stay, while only 13 (33%) of 40 with hypotension survived (p less than .05). Neither initial, peak nor change in BUN or creatinine predicted mortality; oliguria was marginally associated with poor prognosis. Our findings indicate that: a) ARI was a frequent and important contributing factor to mortality in our critically ill patients, b) hypotension was the most common of well-recognized risk factors, and c) conditions that predisposed to ARI also predisposed to mortality, although mortality did not appear to depend on the severity of renal insufficiency.

[Transplantation of autologous skeletal myoblasts in ischemic cardiac insufficiency]. / Transplantation de myoblastes squelettiques autologues dans l'insuffisance cardiaque ischémique.

Despite medical therapeutic advances, congestive heart failure (CHF), which is the common ultimate consequence of many primary cardiovascular diseases, remains a major and growing public health problem. Although orthotopic heart transplantation is the gold standard, there is now growing evidence that one therapeutic option could be cellular cardiomyoplasty. Autologous adult skeletal myoblast transplantation seems to be the most clinically relevant, compared with other cell types, in that it avoids immunosuppression therapy, availability and ethical issues. Previous experimental studies have documented the efficacy of myoblast transplantation in improving function of infarcted myocardium. Although the mechanisms involved in this improvement are not elucidated, it has been demonstrated convincingly enough to consider ripping to clinical trials.