摘要:

ObjectiveTo summarize our institutional experience concerning mechanical ventilation support and blood gas measurements in the 24-hr period following extracorporeal life support (ECLS) for pediatric acute respiratory failure.DesignDescriptive study.SettingA tertiary pediatric referral center.PatientsChildren aged 1 month to 18 yrs treated with ECLS for acute respiratory failure at University of Michigan Hospitals from November 1982 to June 1993. All patients aged 1 month to 18 yrs who received ECLS for acute respiratory failure were included. Patients who received ECLS primarily for cardiac support or who had a diagnosis of congenital gastrointestinal malformation (i.e., congenital diaphragmatic hernia) were excluded.InterventionsECLS for severe pediatric respiratory failure.Measurements and Main ResultsForty-nine children were treated at our center with ECLS for acute respiratory failure and 36 (73%) survived. Ventilator settings immediately after decannulation from ECLS for survivors were as follows: FIO20.53 plus minus 0.18 (SD); intermittent mandatory ventilation (IMV) 29.6 plus minus 11.8 breaths/min, positive end-expiratory pressure 5.3 plus minus 1.6 cm H2O, mean airway pressure 12.6 plus minus 2.9 cm H2O, and peak inspiratory pressure 31.7 plus minus 5.5 cm H2O. Arterial blood gas measurements at decannulation were PaO289.4 plus minus 30.9 torr (11.9 plus minus 4.1 kPa), PaCO243.7 plus minus 9.7 torr (5.8 plus minus 1.3 kPa), and pH 7.39 plus minus 0.07. Twenty-four hours after decannulation, ventilator settings and arterial blood gas measurements were as follows: FIO20.42 plus minus 0.14, IMV 27.4 plus minus 13.5 breaths/min, positive end-expiratory pressure 5.2 plus minus 1.6 cm H2O, mean airway pressure 12.0 plus minus 3.4 cm H2O, peak inspiratory pressure 31.1 plus minus 6.5 cm H2O, PaO277.0 plus minus 16.9 torr (10.3 plus minus 2.3 kPa), PaCO244.9 plus minus 8.4 torr (6.0 plus minus 1.1 kPa), and pH 7.40 plus minus 0.07. Variables associated with oxygenation status (P[A-a]o2) and mean airway pressure (oxygenation index) improved during the immediate 24-hr period postbypass (p less than .05).ConclusionsSuccessful decannulation from ECLS for more than 24 hrs resulted in long-term survival in 97% (36/37) of children. Ventilator parameters and arterial blood gas measurements during the 24-hr period following bypass have been described for this population. Such conventional support may indicate safe levels of oxygen and mechanical ventilation pressures for the postbypass recovering lung.(Crit Care Med 1996; 24:679-682)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveAs part of the overall quality assurance program for the Department of Pediatrics, we determined whether there were differences in the rates of unexpected autopsy findings between pediatric intensive care unit (ICU), emergency department, and ward patients.DesignProspective, descriptive study.SettingTertiary care children's hospital.PatientsPediatric deaths (n equals 212).InterventionsNone.Measurements and Main ResultsAutopsies were obtained more frequently in emergency department patients (27/29 [93%]) compared with pediatric ICU (88/121 [73%]) and ward (42/62 [68%]) patients (p equals .03). The medical examiner's cases were more frequently from emergency department patients (22/27 [81%]) compared with pediatric ICU (39/88 [44%]) or ward (11/42 [26%]) patients (p less than .001). We found unexpected autopsy findings in 19 (12%) of 157 patients. There were no unexpected findings from the medical examiner's cases. The most common unexpected findings were unidentified infections (n equals 7 [three fungal, three viral, and one nonspecific]) and unrecognized cardiac malformations (n equals 4). Unexpected findings occurred more frequently in pediatric ICU patients (16/88 [18%]) vs. emergency department (2/27 [7%]) or ward (1/42 [2%]) patients (p equals .03). The occurrence rates of major unexpected findings (Class I and II) in pediatric ICU (7/79 [9%]), emergency department (2/27 [7%]), and ward (1/42 [2%]) patients were similar (p equals .4). There were two Goldman's Class I unexpected findings in the pediatric ICU and emergency department patients, and one Goldman's Class I unexpected finding in the ward patients.ConclusionsAutopsies were performed more frequently in emergency department patients. Class I through IV unexpected findings occurred more frequently in pediatric ICU patients compared with emergency department or ward patients. Autopsy examinations are an especially valuable diagnostic tool for pediatric ICU patients and physicians.(Crit Care Med 1996; 24:683-686)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo determine the published incidence of adult respiratory distress syndrome (ARDS) as well as the clinical evidence supporting a causal association between ARDS and its major risk factors.Data SourcesThe National Library of Medicine MEDLINE database and the bibliographies of selected articles.Study SelectionClinical studies were selected from the English literature, if they pertained to either the incidence of ARDS or its association with one or more commonly identified risk factors.Data ExtractionAll relevant studies identified by the search were evaluated for strength of design, and risk factors were scored according to established criteria for the strength of causation.Data SynthesisA total of 83 articles were considered relevant: six on incidence and 77 on risk factors. Only 49% of the 83 articles provided a definition of ARDS; a definition of risk factors was given in 64%, and 23% had no definition for either ARDS or risk factors. The published, population-based incidence of ARDS ranges from 1.5 to 5.3/105population/yr. The strongest clinical evidence supporting a cause-effect relationship was identified for sepsis, aspiration, trauma, and multiple transfusions. The weakest clinical evidence was identified for disseminated intravascular coagulation. The following study types were represented by the 77 articles on risk factors: observational case-series (56%); cohorts (23%); case-controls (12%); nonrandomized clinical trials (5%); and randomized clinical trials (3%). Only a single study reported an odds ratio.ConclusionsThe significant variation in the incidence of ARDS is attributed to differences in the type and strength of study designs, as well as definitions of ARDS. While a substantial body of evidence exists concerning a causal role for ARDS risk factors, such as sepsis, aspiration, and trauma, more than 60% of clinical studies employed weak designs. The lack of reproducible definitions for ARDS or its potential risk factors in 49% of studies raises concerns about the validity of the conclusions of these studies regarding the association between ARDS and the supposed risk factors.(Crit Care Med 1996; 24:687-695)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

ObjectiveTo analyze the status of the teaching of critical care at the postgraduate and undergraduate levels in Europe.Data SourcesTwo types of questionnaires were sent in order to collect data. The first questionnaire was sent to the heads of the intensive care units (ICUs) of at least five of the major hospitals in each western country of the European Region of the World Health Organization and to the people responsible for specialist training in the Eastern countries. Countries in the former USSR and former Yugoslavia were excluded; 50 questionnaires (of 105) were returned. The second questionnaire was sent to the 374 medical schools in the European Region; 253 were returned although only 185 were selected for this article.ResultsPostgraduate and undergraduate training differ widely in terms of the content of, and disciplines in charge of, the teaching of critical care. Even countries of the World Health Organization's European Region, where critical care is a recognized clinical specialty, do not have an academic discipline of critical care. This lack of an established academic discipline of critical care contributes to the diversity in teaching critical care in medical schools in the countries we studied. Postgraduate training is more formally regulated, and objectives and guidelines have been established in many countries. The topics in medical schools that correspond to critical care medicine do not encompass a distinct body of knowledge and are distributed among more traditional disciplines, most frequently internal medicine, anesthesiology, and surgery. The critical care medicine experience afforded to undergraduates varies widely between and within countries. The repetition of critical care conditions for which patients receive critical care in several disciplines, as described by the responses, leads us to wonder whether these conditions are really included in the curriculum.ConclusionsThe standardization of curriculum content on critical care medicine, the clear definition of competence (the combination of knowledge, attitudes, skills, and judgment necessary to practice) in medical schools, and better coordinated postgraduate training are needed to clarify an educational approach in the field. Practitioners of critical care medicine will have to participate actively on curriculum committees. The recognition of critical care medicine as a specialty or subspecialty and as an academic discipline will facilitate the achievement of a comprehensive critical care education program.(Crit Care Med 1996; 24:696-704)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

Objectivesa) To describe the introduction of noninvasive means to provide positive-pressure ventilation in acute respiratory failure; b) to describe the physiologic response to noninvasive ventilation; c) to review the current published literature on using noninvasive ventilation in patients with acute hypercapnic and/or hypoxemic respiratory failure; d) to describe the technique of applying mask ventilation and current recommendations for using noninvasive ventilation in patients with acute respiratory failure; and e) to discuss the advantages and disadvantages of noninvasive ventilation.Data SourcesAll relevant articles published in the English medical literature from 1988 through August 1994 were retrieved through a MEDLINE search, as well as from the authors' experience.Study SelectionStudies were selected based on the use of positive-pressure mechanical ventilation delivered, using facial or nasal masks in various acute settings of respiratory failure.Data ExtractionThe authors extracted all applicable data.Data SynthesisStudies were analyzed according to the type of respiratory failure (hypercapnic vs. hypoxemic) and the underlying conditions where noninvasive ventilation seemed to be a better alternative. The results were evaluated based on types of masks used and modes of ventilation. Outcome measures were compared based on studies that randomized patients with acute respiratory failure to receive noninvasive ventilation vs. conventional therapy. Complications of noninvasive ventilation, mainly local, were compared with those complications seen with endotracheal intubation in acute respiratory failure patients.ConclusionsNoninvasive ventilation is a safe and effective means of ventilatory support for many patients with acute respiratory failure, particularly those patients with hypercapnic respiratory failure. Noninvasive ventilation is well tolerated, principally because it allows the patient to be in control and to continue verbal communication, and should be strongly considered in managing terminally ill patients with potentially reversible causes of respiratory failure. The duration of mechanical ventilation and its associated complications are significantly decreased in hypercapnic respiratory failure with noninvasive ventilation.(Crit Care Med 1996; 24:705-715)

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0090-3493    

出版商:OVID    

年代:1996

数据来源: OVID