Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical PatientsThe development of the balloon-tipped flow-directed pulmonary artery (PA) catheter by Swan and colleagues has led to the widespread application of invasive hemodynamic monitoring in critically ill patients. Although criteria for therapy have been tacitly assumed to be normal values, increased hemodynamic and oxygen transport variables observed in survivors raise questions regarding therapeutic goals. Therapeutic goals for cardiac patients whose other vital organs are unimpaired may be different from those of the postoperative general surgical patient whose cardiac function is normal but whose metabolic demands are increased. The problems of the noncardiac general surgical patient may be of interest to the medical consultant and to the internist who inserts PA catheters to monitor these patients. in detail Read the rest of this entry »

In the present study, there were no significant changes found in any cardiorespiratory parameters after the initiation of PC-IRV at an I:E ratio of 2:1. In particular, Cl, Do2, and Vo2 remained unaltered by the use of PC-IRV These results demonstrate that the improvement in oxygenation which accompanies use of PC-IRV at this I:E ratio is not associated with any deleterious effects on cardiac function or tissue oxygen delivery. Because higher I:E ratios were not utilized in this study, it is not possible to be sure that cardiorespiratory parameters would remain unchanged as the I:E ratio is further increased. Read the rest of this entry »

In the present study, increases in Pa02 and decreases in PIP were found after the initiation of PC-IRV These results are similar to those found in previous investigations* of PC-IRV The changes found in PaC02 and pH were minimal and probably could have been eliminated had the end-expiratory pressure been decreased, as was made possible by the improvement in oxygenation accompanying the use of PC-IRV. Because PC-IRV has been demonstrated to result in improved Pa02 and decreased PIP in patients with ARDS, it has been proposed as a useful ventilatory modality for severe respiratory failure. Although no clear improvement in patient outcome has yet been shown with the use of PC-IRV, several theoretic benefits are associated with its physiologic effects. Improved oxygenation as a result of PC-IRV in patients with ARDS will permit use of lower inspired concentrations of oxygen, minimizing pulmonary toxicity associated with high FIo2. High PIP is thought to contribute to barotrauma and pulmonary injury through the generation of elevated alveolar shear forces. Maintenance or improvement of oxygenation with PC-IRV at lower levels of PIP may decrease the incidence of these complications of mechanical ventilation. fully Read the rest of this entry »

Cardiorespiratory Effects of Pressure Controlled Inverse Ratio Ventilation in Severe Respiratory Failure: ResultsData Analysis
Derived cardiorespiratory variables, systemic vascular resistance, pulmonary vascular resistance, arterial and mixed venous oxygen content, oxygen delivery, oxygen consumption, and oxygen extraction ratio were calculated using standard and previously described formulae. Where appropriate, cardiorespiratory and hemodynamic variables were normalized, using the calculated body surface area for each patient. Mean ± standard error of the mean was calculated for each of the cardiorespiratory variables, both before and after institution of PC-IRV. Comparison between values before and after initiation of PC-IRV was performed by a paired Students f-test. Differences were considered to be significant for p<0.05. read Read the rest of this entry »

Nine patients (Table 1) with severe ARDS, as manifested by diffuse pulmonary infiltrates on chest roentgenograms, arterial hypoxemia with widened A-a gradients despite supplemental oxygen, pulmonary capillary wedge pressures (WP) less than 20 mm Hg, and decreased static and dynamic thoracic compliance were entered in the study. In each case, the patient was placed on PC-IRV at the request of the attending physician, who judged the patient to be failing conventional volume contrblled ventilation with conventional ratios (VC-CRV). In all cases, a flow-directed pulmonary artery (Swan-Ganz) catheter with a fiberoptic channel for continuous measurement of mixed venous oxygen saturation had been placed previously for hemodynamic and cardiorespiratory monitoring. The mixed venous oxygen saturation determination from the pulmonary artery catheter was calibrated and verified by using a mixed venous blood sample in which the oxygen saturation was measured by COoximetry. All patients had indwelling arterial catheters and pulse oximeters. All patients previously had been placed on a Servo-controlled ventilator, operating in the volume controlled ventilation mode. Prior to initiation of the PC-IRV trial, all patients were sedated with appropriate doses of benzodiazepines and paralyzed with vecuronium or atracurium by continuous intravenous infusion, after an initial bolus dose. More info Read the rest of this entry »

Cardiorespiratory Effects of Pressure Controlled Inverse Ratio Ventilation in Severe Respiratory FailurePressure controlled inverse ratio ventilation is a recently described-2 ventilatory modality, in which the conventional inspiratory to expiratory (I:E) ratio is reversed, with the inspiratory phase becoming two to four times as long as the expiratory period. The PC-IRV has been reported to achieve improved oxygenation at lower peak airway pressures. Other advantages include lower minute volume and decreased levels of positive end expiratory pressure. In PC-IRY pressure control is used to change the inspiratory flow pattern so that each breath is initiated before expiratory flow from the previous breath reaches zero. A physiologic result of this ventilatory pattern is maintenance of end-expiratory pressures. The prolonged inspiratory phase, coupled with positive end-expiratory pressure, usually results in decreased peak inspiratory and increased mean airway pressures in patients receiving PC-IRV. Read the rest of this entry »

Hemodynamic Disturbances and Va/Q Matching in Hypoxemic Cirrhotic Patients: ConclusionThese results are consistent with those of Daoud et al; however, two comments on Pv02, which was not measured in the previously cited study, should be made: (1) since a fall in Pv02 appears to contribute significantly to the HPV response magnitude, the hyperkinetic heart syndrome restoring normal Pv02 may have played a role in the impairment of the HPV mechanism even in the presence of hypoxemia; and (2) although many factors led to a raised cardiac output, the rise was exactly adjusted to maintain a normal Pv02. Read the rest of this entry »

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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.




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