2,075 research outputs found
Management of early ARDS
No full textInteractive session presenting a clinical case of ARDS with questions and discussion on the specific management of the patient in the early phase of the pathology. Discussion conducted by Luciano Gattinoni and JJ Marin
hemodynamics and energy failure
No full textAdequate hemodynamics not only means adequate blood flow and arterial pressure values but also an oxygen supply necessary to properly answer to biological needs. Proper oxygenation is synonymous of proper energy supply. Energy failure is a life threatening condition that can be due not only to hemodynamic insufficiency but also to mitochondrial impairment or a combination of the two. Challenge tests are available to assess the origin of energy failure, i.e. volume load and dobutamine test. If the response to this tests is an increased oxygen consumption and a decrease of lactate and its correlates due to an increased oxygen transport the mitochondrial function is still adequate. If oxygen consumption does not increase mitochondrial function is impaired due to a direct insult or long-lasting hypoxia. It appears quite clear that an aggressive hemodynamic treatment is useless in case of mitochondrial dysfunction. Moreover long-lasting energy failure may lead to mitochondrial disfunction of secondary origin.
According to the observation that patients with higher mean CI, DO2 and VO2 had better outcome, “supra-normal hemodynamic values” became the target of several studies and of the treatment of intensive care patients. Hoewever Hayes et al. found that the mortality of patients targeted on “supra-normal values” presented higher mortality, while Gattinoni et al found that patients targeted to obtain supra-normal hemodynamic values, normal values or SVO2 >70% had the same mortality. On the contrary Rivers et al, 10 years later the study of Gattinoni, found that septic patients targeted to SvO2 > 70% had a better outcome than the ones treated to have an adequate arterial pressure. The possible reasons of these discrepancies may be due to the different times of intervention. It is possible, in fact, that in critically ill patients short times of intervention may solve the energy failure avoiding mitochondrial impairment. Analyzing the different studies, Shoemaker enrolled peri-operative patients, Rivers enrolled patients in emergency room 2 hours before the intensive care unit (ICU) entry, while Gattinoni’s study analyzed a general ICU population (up to 72 hours). It is then conceivable that the positive results found by Shoemaker and Rivers were not found by Gattinoni. Accordingly a meta-analysis by Kern and Shoemaker pointed out that only rapid interventions may reduce mortality. On this wavelength are even the Surviving Sepsis Campaign guidelines that suggest within the first 6 hours of treatment: central venous pressure within 8-12 mmH, mean arterial pressure higher than 65 mmHg, urinary output higher than 0.5 ml/kg/hr, ScvO2 >65% or SvO2 > 70%. In conclusion, time is essential as an early treatment of hemodynamic failure is likely associated with improved survival, before an irreversible mitochondrial damag
Supporting hemodynamics : what should we target? What treatments should we use?
No full textAdequate hemodynamics not only means adequate blood flow and arterial pressure values but also an oxygen supply necessary to properly answer to biological needs. Proper oxygenation is synonymous of proper energy supply. Energy failure is a life threatening condition that can be due not only to hemodynamic insufficiency but also to mitochondrial impairment or a combination of the two. Challenge tests are available to assess the origin of energy failure, i.e. volume load and dobutamine test. If the response to this tests is an increased oxygen consumption and a decrease of lactate and its correlates due to an increased oxygen transport the mitochondrial function is still adequate. If oxygen consumption does not increase mitochondrial function is impaired due to a direct insult or long-lasting hypoxia. It appears quite clear that an aggressive hemodynamic treatment is useless in case of mitochondrial dysfunction. Moreover long-lasting energy failure may lead to mitochondrial disfunction of secondary origin.
According to the observation that patients with higher mean CI, DO2 and VO2 had better outcome, “supra-normal hemodynamic values” became the target of several studies and of the treatment of intensive care patients. Hoewever Hayes et al. found that the mortality of patients targeted on “supra-normal values” presented higher mortality, while Gattinoni et al found that patients targeted to obtain supra-normal hemodynamic values, normal values or SVO2 >70% had the same mortality. On the contrary Rivers et al, 10 years later the study of Gattinoni, found that septic patients targeted to SvO2 > 70% had a better outcome than the ones treated to have an adequate arterial pressure. The possible reasons of these discrepancies may be due to the different times of intervention. It is possible, in fact, that in critically ill patients short times of intervention may solve the energy failure avoiding mitochondrial impairment. Analyzing the different studies, Shoemaker enrolled peri-operative patients, Rivers enrolled patients in emergency room 2 hours before the intensive care unit (ICU) entry, while Gattinoni’s study analyzed a general ICU population (up to 72 hours). It is then conceivable that the positive results found by Shoemaker and Rivers were not found by Gattinoni. Accordingly a meta-analysis by Kern and Shoemaker pointed out that only rapid interventions may reduce mortality. On this wavelength are even the Surviving Sepsis Campaign guidelines that suggest within the first 6 hours of treatment: central venous pressure within 8-12 mmH, mean arterial pressure higher than 65 mmHg, urinary output higher than 0.5 ml/kg/hr, ScvO2 >65% or SvO2 > 70%. In conclusion, time is essential as an early treatment of hemodynamic failure is likely associated with improved survival, before an irreversible mitochondrial damage
Curiosity, Opportunity, and Luck: Were the 1970s Different?
No full textControl of Breathing Using an Extracorporeal Membrane Lung. By T Kolobow, L Gattinoni, TA Tomlinson, JE Pierce. Anesthesiology 1977; 46:138–41. Reprinted with permission. Body Position Changes Redistribute Lung Computed-Tomographic Density in Patients with Acute Respiratory Failure. By L Gattinoni, P Pelosi, G Vitale, A Pesenti, L D’Andrea, D Mascheroni. Anesthesiology 1991; 74:15–23. Reprinted with permission. Dr. Gattinoni’s scientific career was primarily driven by curiosity. His generation was not formally trained, but he was part of a community of young and enthusiastic colleagues who were forging a new discipline: intensive care medicine. The most significant opportunity of Dr. Gattinoni’s career was becoming the research fellow of a visionary genius, Dr. Theodor Kolobow, who focused on extracorporeal carbon dioxide removal after the failure of the first trial on extracorporeal membrane oxygenation. CO2 removal, by allowing control over the intensity of mechanical ventilation, opened the path to “lung rest” to prevent ventilator-induced lung injury. A unique opportunity for research was the spontaneous birth of a network of scientists who became friends in the European Group of Research in Intensive Care Medicine. In this environment, it was possible to develop core concepts such as the “baby lung” and to understand the mechanisms underlying computed tomography–density redistribution in the prone position. Physiology guided us in the 1970s, and understanding mechanisms remains of paramount importance today
Avoid hypercapnia : use extracorporeal CO2 removal
No full textExtracorporeal CO2 removal, and extracorporeal oxygenation, in veno-venous bypass, are forms of respiratory support aiming at buying time during the cure of the causative disease. Description of review. The extracorporeal support was first introduced in the seventies. In 1973 the first randomized trial comparing the outcome of patients treated with extra-corporeal support to patients conventionally treated was performed and did not show any survival benefit (mortality equal to about 90%) and most centers, according to this result, abandoned the use of extracorporeal support in the treatment of ARDS patients. The further work of Kolobow and Gattinoni led to the introduction, in the eighties, of the extracorporeal CO2 removal, aiming at the lung rest. Different randomized studies did not show any survival benefit with extracorporeal CO2 removal support, however, the technology available at that time was likely inadequate while, nowadays, it has been greatly improved. It is important to highlight that extracorporeal supports may greatly reduce the need of mechanical ventilation which is associated to the problem of VILI. The recent H1N1 flu epidemics led to an epidemics of respiratory failure with patients considered not safely ventilable even with low tidal volume (6-8 ml/Kg) and safe plateau pressures (below 30-35 cmH2O) leading to renewed interest for extracorporeal support and to the publication of a great number of papers on the topic. Conclusion. Nowadays we believe that extracorporeal techniques, applied in experienced institutions, may become a feasible and promising alternative to mechanical ventilation to fully prevent VILI
Extracorporeal CO2 removal
No full textIntroduction. Extracorporeal CO2 removal, and extracorporeal oxygenation, in veno-venous bypass, are forms of respiratory support aiming at buying time during the cure of the causative disease.
Description of review. The extracorporeal support was first introduced in the seventies. In 1973 the first randomized trial comparing the outcome of patients treated with extra-corporeal support to patients conventionally treated was performed and did not show any survival benefit (mortality equal to about 90%) and most centers, according to this result, abandoned the use of extracorporeal support in the treatment of ARDS patients. The further work of Kolobow and Gattinoni led to the introduction, in the eighties, of the extracorporeal CO2 removal, aiming at the lung rest. Different randomized studies did not show any survival benefit with extracorporeal CO2 removal support, however, the technology available at that time was likely inadequate while, nowadays, it has been greatly improved. It is important to highlight that extracorporeal supports may greatly reduce the need of mechanical ventilation which is associated to the problem of VILI. The recent H1N1 flu epidemics led to an epidemics of respiratory failure with patients considered not safely ventilable even with low tidal volume (6-8 ml/Kg) and safe plateau pressures (below 30-35 cmH2O) leading to renewed interest for extracorporeal support and to the publication of a great number of papers on the topic.
Conclusion. Nowadays we believe that extracorporeal techniques, applied in experienced institutions, may become a feasible and promising alternative to mechanical ventilation to fully prevent VILI
Extracorporeal CO2 removal from 1977 to 2014
No full textIntroduction. Extracorporeal CO2 removal, and extracorporeal oxygenation, in veno-venous bypass, are forms of respiratory support aiming at buying time during the cure of the causative disease.
Description of review. The extracorporeal support was first introduced in the seventies. In 1973 the first randomized trial comparing the outcome of patients treated with extra-corporeal support to patients conventionally treated was performed and did not show any survival benefit (mortality equal to about 90%) and most centers, according to this result, abandoned the use of extracorporeal support in the treatment of ARDS patients. The further work of Kolobow and Gattinoni led to the introduction, in the eighties, of the extracorporeal CO2 removal, aiming at the lung rest. Different randomized studies did not show any survival benefit with extracorporeal CO2 removal support, however, the technology available at that time was likely inadequate while, nowadays, it has been greatly improved. It is important to highlight that extracorporeal supports may greatly reduce the need of mechanical ventilation which is associated to the problem of VILI. The recent H1N1 flu epidemics led to an epidemics of respiratory failure with patients considered not safely ventilable even with low tidal volume (6-8 ml/Kg) and safe plateau pressures (below 30-35 cmH2O) leading to renewed interest for extracorporeal support and to the publication of a great number of papers on the topic.
Conclusion. Nowadays we believe that extracorporeal techniques, applied in experienced institutions, may become a feasible and promising alternative to mechanical ventilation to fully prevent VILI
Extracorporeal support for ARDS: from the origin till H1N1 pandemia
No full textThe extracorporeal support has been used to support circulation and gas exchange and was first introduced in the seventies. The equipment is composed of an external system of tubing that extracts the venous blood from the patient; the blood is driven by a pump to the artificial lung which oxygenates it and removes carbon dioxide. The blood is then circulated back to the patient. In 1973 the first randomized trial comparing the outcome of patients treated with extra-corporeal support to patients conventionally treated was performed and did not show any survival benefit (mortality equal to about 90%) and most centers, according to this result, abandoned the use of extracorporeal support in the treatment of ARDS patients. The further work of Kolobow and Gattinoni led to the introduction, in the eighties, of the extracorporeal CO2 removal, aiming at the lung rest. Different randomized studies did not show any survival benefit with extracorporeal CO2 removal support, however, the technology available at that time was likely inadequate while, nowadays, it has been greatly improved. It is important to highlight that extracorporeal supports may greatly reduce the need of mechanical ventilation which is associated to the problem of VILI. The recent H1N1 flu epidemics led to an epidemics of respiratory failure with patients considered not safely ventilable even with low tidal volume (6-8 ml/Kg) and safe plateau pressures (below 30-35 cmH2O) leading to renewed interest for extracorporeal support and to the publication of a great number of papers on the topic. Nowadays we believe that extracorporeal techniques, applied in experienced institutions, may become a feasible and promising alternative to mechanical ventilation to fully prevent VILI
Extracorporeal support as an alternative to mechanical ventilation
No full textThe extracorporeal support has been used to support circulation and gas exchange and was first introduced in the seventies. The equipment is composed of an external system of tubing that extracts the venous blood from the patient; the blood is driven by a pump to the artificial lung which oxygenates it and removes carbon dioxide. The blood is then circulated back to the patient. In 1973 the first randomized trial comparing the outcome of patients treated with extra-corporeal support to patients conventionally treated was performed and did not show any survival benefit (mortality equal to about 90%) and most centers, according to this result, abandoned the use of extracorporeal support in the treatment of ARDS patients. The further work of Kolobow and Gattinoni led to the introduction, in the eighties, of the extracorporeal CO2 removal, aiming at the lung rest. Different randomized studies did not show any survival benefit with extracorporeal CO2 removal support, however, the technology available at that time was likely inadequate while, nowadays, it has been greatly improved. It is important to highlight that extracorporeal supports may greatly reduce the need of mechanical ventilation which is associated to the problem of VILI. The recent H1N1 flu epidemics led to an epidemics of respiratory failure with patients considered not safely ventilable even with low tidal volume (6-8 ml/Kg) and safe plateau pressures (below 30-35 cmH2O) leading to renewed interest for extracorporeal support and to the publication of a great number of papers on the topic. Nowadays we believe that extracorporeal techniques, applied in experienced institutions, may become a feasible and promising alternative to mechanical ventilation to fully prevent VILI
- …
