1,721,042 research outputs found
Complications of Mechanical Ventilation
No full textMechanical ventilation is a life support measure that is frequently needed in cases of respiratory failure. Its purposes are many, including amelioration of gas exchange, the decrease of oxygen consumption of respiratory muscles (thus increasing the oxygen available to vital organs) and the reversal of respiratory muscles fatigue. Unfortunately, mechanical ventilation itself can be a source of complications, and among others we cite ventilator induced lung injury, ventilator associated pneumonia and diaphragm dysfunction
Personalizing beta-lactams therapy in critical patients undergoing RRT: moving a further step forward?
No full textQuadratus Lumborum Block for Incarcerated Hernia Repair in a Multi-Morbid Elderly Patient: A Letter to Editor
No full textRespiratory consequences of intra-abdominal hypertension
No full textIntra-abdominal hypertension (IAH) is a common complication in critically ill patients that may lead to multiorgan failure and is associated to worse outcome. Respiratory failure is among the most important consequences of IAH and it is originated by different mechanisms, such as chest wall elastance increase, functional residual capacity reduction, compression atelectasis and lung edema formation through reduction in lymphatic drainage. Many experimental studies showed that total lung capacity and functional residual capacity can be decreased by 40% during abdominal hypertension, while respiratory system and chest wall pressure-volume curves can be significantly shifted downward and to the right. Moreover, the relationship between intra-abdominal volume and airway pressure has been found to be exponential, meaning that small increases in volume can translate in dramatic increases in pressure. Clinical studies confirmed relevant atelectasis in dependent lung regions during IAH, with significant reductions in functional residual capacity and compromised oxygenation. Moreover, sepsis-related capillary leak and fluid overload may aggravate IAH and respiratory failure, thus establishing a dangerous vicious circle. Respiratory management of patients with IAH is challenging and there is no univocal answer. The measurement of intra-abdominal pressure and esophageal pressure (as a surrogate of pleural pressure) may be useful in assessing the condition and guiding mechanical ventilation. Positive end- expiratory pressure (PEEP) must be carefully selected to counteract IAH-related diaphragm displacement, but too high PEEP levels are associated with hemodynamic failure. Continuous negative extra-abdominal pressure is a promising approach, but its clinical application needs more investigation
Protective ventilation in patients with acute respiratory distress syndrome related to COVID-19: always, sometimes or never?
No full textPurpose of review: To review current evidence on the pathophysiology of COVID-19-related acute respiratory distress syndrome (ARDS) and on the implementation of lung protective ventilation. Recent findings: Although multiple observations and physiological studies seem to show a different pathophysiological behaviour in COVID-19-ARDS compared with 'classical' ARDS, numerous studies on thousands of patients do not confirm these findings and COVID-19-ARDS indeed shares similar characteristics and interindividual heterogeneity with ARDS from other causes. Although still scarce, present evidence on the application of lung protective ventilation in COVID-19-ARDS shows that it is indeed consistently applied in ICUs worldwide with a possible signal towards better survival at least in one study. The levels of positive end-expiratory pressure (PEEP) usually applied in these patients are higher than in 'classical' ARDS, proposing once again the issue of PEEP personalization in hypoxemic patients. In the absence of robust evidence, careful evaluation of the patient is needed, and empiric settings should be oriented towards lower levels of PEEP. Summary: According to the present evidence, a lung protective strategy based on low tidal volume and plateau pressures is indicated in COVID-19-ARDS as in ARDS from other causes; however, there are still uncertainties on the appropriate levels of PEEP
Alveolar recruitment in acute respiratory distress syndrome: should we open the lung (no matter what) or may accept (part of) the lung closed?
No full text
Erector spinae plane block as a multiple catheter technique for open esophagectomy: a case report
Full text linkBackground and objective: Erector spinae plane block is a valid technique to provide simultaneously analgesia for combined thoracic and abdominal surgery. Case report: A patient underwent open esophagectomy followed by reconstructive esophagogastroplasty but refused thoracic epidural analgesia; a multi-modal analgesia with a multiple erector spinae plane block was then planned. Three erector spinae plane catheters (T5 and T10 on the right side and T9 on the left side) for continuous analgesia were placed before surgery. During the first 48 h pain was never reported in the thoracic area but the patient reported multiple times to feel a pain well localized in epigastrium, but never localized in any other abdominal quadrant. Discussion: Erector spinae plane block is a valid technique to provide analgesia simultaneously for combined thoracic and abdominal surgery and could be a valid alternative strategy if the use of epidural analgesia is contraindicated. Resumo: Justificativa e objetivo: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia em cirurgias combinadas, torácica e abdominal, de modo simultâneo. Relato de caso: Um paciente foi submetido à esofagectomia aberta seguida de esofagogastroplastia reconstrutiva, mas recusou analgesia peridural torácica; uma analgesia multimodal com o bloqueio dos múltiplos segmentos do eretor da espinha foi então planejada. Três cateteres foram colocados no plano do eretor da espinha (T5 e T10 no lado direito e T9 no lado esquerdo) para analgesia contínua antes da cirurgia. Durante as primeiras 48 horas, não houve queixa de dor na área torácica, mas várias vezes o paciente relatou sentir uma dor bem localizada no epigástrio, mas nunca localizada em nenhum outro quadrante abdominal. Discussão: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia de modo simultâneo em cirurgias combinadas — torácica e abdominal — e pode ser uma estratégia alternativa também válida nos casos em que o uso de analgesia peridural for contraindicado. Keywords: Erector spinae plane block, Regional anesthesia, Esophagectomy, Palavras-chave: Bloqueio do plano do eretor da espinha, Anestesia regional, Esofagectomi
How best to set the ventilator on extracorporeal membrane lung oxygenation
No full textPurpose of review Extracorporeal respiratory support in patients with acute respiratory distress syndrome is applied either as rescue maneuver for life-threatening hypoxemia or as a tool to reduce the harm of mechanical ventilation. Depending on the blood and gas flow, extracorporeal support may completely substitute the natural lung as a gas exchanger (high-flow venovenous bypass) or reduce the need for mechanical ventilation, enabling the removal of a fraction of the metabolically produced CO2. Recent findings Recent studies provide a description on how mechanical ventilation is normally applied in combination with extracorporeal support in acute respiratory distress syndrome. The data show a general trend: a variable decrease of fraction of inspired oxygen (0.9 to 0.7 or 0.4), a consistent decrease in tidal volume (by 2 ml/ kg), no change in positive end-expiratory pressure (maintained around 12-13cmH2O) and a moderate decrease in the respiratory rate (22 to 15 bpm). These ventilatory settings are applied in whatever extracorporeal membrane lung oxygenation modality (venovenous versus venoarterial) and independent from the extent of extracorporeal support (partial or total substitution of gas exchange). Summary Mechanical ventilation and extracorporeal support are marginally integrated. The best environment for lung healing - complete lung collapse or protective ventilation strategy or fully open and immobile lung (all three conditions feasible with extracorporeal support) - remains to be defined
Balancing the scales: achieving the optimal beta-lactam to beta-lactamase inhibitor ratio with continuous infusion piperacillin/tazobactam against extended spectrum beta-lactamase producing Enterobacterales
Full text linkPiperacillin/tazobactam (TZP) is administered intravenously in a fixed ratio (8:1) with the potential for inadequate tazobactam exposure to ensure piperacillin activity against Enterobacterales. Adult patients receiving continuous infusion (CI) of TZP and therapeutic drug monitoring (TDM) of both agents were evaluated. Demographic variables and other pertinent laboratory data were collected retrospectively. A population pharmacokinetic approach was used to select the best kidney function model predictive of TZP clearance (CL). The probability of target attainment (PTA), cumulative fraction of response (CFR) and the ratio between piperacillin and tazobactam were computed to identify optimal dosage regimens by continuous infusion across kidney function. This study included 257 critically ill patients (79.3% male) with intra-abdominal, bloodstream, and hospital-acquired pneumonia infections in 89.5% as the primary indication. The median (min-max range) age, body weight, and estimated glomerular filtration rate (eGFR) were 66 (23-93) years, 75 (39-310) kg, and 79.2 (6.4-234) mL/min, respectively. Doses of up to 22.5 g/day were used to optimize TZP based on TDM. The 2021 chronic kidney disease epidemiology equation in mL/min best modeled TZP CL. The ratio of piperacillin:tazobactam increased from 6:1 to 10:1 between an eGFR of <20 mL/min and >120 mL/min. At conventional doses, the PTA is below 90% when eGFR is ≥100 mL/min. Daily doses of 18 g/day and 22.5 g/day by CI are expected to achieve a >80% CFR when eGFR is 100-120 mL/min and >120-160 mL/min, respectively. Inadequate piperacillin and tazobactam exposure is likely in patients with eGFR ≥ 100 mL/min. Dose regimen adjustments informed by TDM should be evaluated in this specific population
- …
