Andrew W. Holt

Treatment of Severe Cardiogenic Pulmonary Edema with Continuous Positive Airway Pressure Delivered by Face Mask

BACKGROUND Severe cardiogenic pulmonary edema is a frequent cause of respiratory failure, and many patients with this condition require endotracheal intubation and mechanical ventilation. We investigated whether continuous positive airway pressure delivered by means of a face mask had physiologic benefit and would reduce the need for intubation and mechanical ventilation. METHODS We randomly assigned 39 consecutive patients with respiratory failure due to severe cardiogenic pulmonary edema to receive either oxygen alone or oxygen plus continuous positive airway pressure delivered through a face mask. It was not possible to blind the investigators to the assigned treatment. Physiologic measurements were made over the subsequent 24 hours, and the patients were followed to hospital discharge. RESULTS After 30 minutes, both respiratory rate and arterial carbon dioxide tension had decreased more in the patients who received oxygen plus continuous positive airway pressure. The mean (+/- SD) respiratory rate at 30 minutes decreased from 32 +/- 6 to 33 +/- 9 breaths per minute in the patients receiving oxygen alone and from 35 +/- 8 to 27 +/- 6 breaths per minute in those receiving oxygen plus continuous positive airway pressure (P = 0.008); the arterial carbon dioxide tension decreased from 64 +/- 17 to 62 +/- 14 mm Hg in those receiving oxygen alone and from 58 +/- 8 to 46 +/- 4 mm Hg in those receiving oxygen plus continuous positive airway pressure (P less than 0.001). The patients receiving continuous positive airway pressure also had a greater increase in the arterial pH (oxygen alone, from 7.15 +/- 0.11 to 7.18 +/- 0.18; oxygen plus continuous positive airway pressure, from 7.18 +/- 0.08 to 7.28 +/- 0.06; P less than 0.001) and in the ratio of arterial oxygen tension to the fraction of inspired oxygen (oxygen alone, from 136 +/- 44 to 126 +/- 47; oxygen plus continuous positive airway pressure, from 138 +/- 32 to 206 +/- 126; P = 0.01). After 24 hours, however, there were no significant differences between the two treatment groups in any of these respiratory indexes. Seven (35 percent) of the patients who received oxygen alone but none who received oxygen plus continuous positive airway pressure required intubation and mechanical ventilation (P = 0.005). However, no significant difference was found in in-hospital mortality (oxygen alone, 4 of 20 patients; oxygen plus continuous positive airway pressure, 2 of 19; P = 0.36) or the length of the hospital stay. CONCLUSIONS Continuous positive airway pressure delivered by face mask in patients with severe cardiogenic pulmonary edema can result in early physiologic improvement and reduce the need for intubation and mechanical ventilation. This short-term study could not establish whether continuous positive airway pressure has any long-term benefit or whether a larger study would have shown a difference in mortality between the treatment groups.

Treatment of a Giant Haemangioma of the Liver With Kasabach-Merritt Syndrome by Orthotopic Liver Transplant

We describe a case of giant cavernous haemangioma of the liver with disseminated intravascular coagulopathy (Kasabach-Merritt syndrome) which was cured by orthotopic liver transplant. A 47 year old man presented with bleeding and tender massive hepatomegaly after tooth extraction. Investigations showed disseminated intravascular coagulopathy and a giant hepatic haemangioma involving both lobes of the liver. Initial treatment failed to resolve the coagulopathy and liver resection was attempted. At laparotomy the turnout was unresectable and the only option for cure was to offer a liver transplantation. The orthotopic liver transplant was performed 20 days after initial laparotomy. Subsequently, all coagulation parameters returned to normal and the patient remains well after 12 months. Orthotopic liver transplant can be considered for giant hepatic haemangioma with Kasabach-Merritt syndrome when resection is necessary and a partial hepatectomy is not technically feasible.

Maxon is an Optimal Suture for Bile Duct Anastomoses in Pigs

Background. Three commonly used sutures were tested in a pig model of bile duct anastomosis to assess their relative contributions to inflammation and scarring. Methods. Thirty pigs were randomised to bile duct division and anastomosis with either polyglyconate (Maxon), polyglactin 910 (Vicryl) or polypropylene (Prolene). Half the animals were sacrificed at two weeks and the remainder at 23 weeks. Anastomoses were assessed by cholangiography, scanning electron microscopy and light microscopy. Results. There was less short term histological reaction with the two monofilament materials, Prolene and Maxon, compared to the braided suture Vicryl. Maxon was associated with less long term inflammation than Prolene, was found to handle better, and has an advantage over Prolene by being absorbable. Conclusion. Maxon is an optimal suture for bile duct anastomoses. Its long term absorption characteristics make it suitable for situations where bile duct healing may be delayed.

Hemodynamic factors influencing renal blood flow

Renal dysfunction remains a common, complex problem in critically ill patients. It may be estimated that ischemia contributes to 85% of cases of acute renal failure (ARF) [1], since, in addition to obvious causes of ischemic ARF, Brezis and associates [2] have shown that numerous nephrotoxins, including radiocontrast dyes, non-steroidal anti-inflammatory drugs, amphotericin, myoglobin and cyclosporin, exacerbate medullary hypoxia. However, ARF usually represents the combined effects of multiple insults. Given the conflicting evidence regarding mechanisms of renal injury and dysfunction (direct toxic effects, tubular obstruction, transtubular backleakage of filtrate, global renal ischemia, medullary ischemia, activated neutrophils and adhesion molecules, inflammatory mediators and tubuloglomerular feed back), it is impossible to accurately quantify their relative importance. It is also clear that these are not isolated effects, and that complex interactions result in clinical ARF. For example, renal ischemia results in priming, and an oxygen metabolite mediated retention, of neutrophils, which exacerbates renal injury and dysfunction [3]. In turn, when activated neutrophils are initially present, short periods of ischemia, that by themselves do not cause damage, now result in ARF [3]. This may explain why endotoxin and renal ischemia combine synergistically to produce ARF [4]. Finally, some authors have suggested that polymorph-endothelial interactions contribute to medullary congestion, and an exacerbation of medullary ischemia [5].

Addition of indapamide to frusemide increases natriuresis and creatinine clearance, but not diuresis, in fluid overloaded ICU patients

BACKGROUND Fluid and sodium overload are a common problem in critically ill patients. Frusemide may result in diuresis in excess of natriuresis. The addition of indapamide may achieve a greater natriuresis, and also circumvent some of the problems associated with frusemide. The objective of this study was to examine the effect of adding indapamide to frusemide on diuresis, natriuresis, creatinine clearance and serum electrolytes. METHODS Fluid overloaded ICU patients were randomised to either intravenous frusemide (Group F) or intravenous frusemide and enteral indapamide (Group F + I). Comprehensive exclusion criteria were applied to address confounders. 24 hour urine was analysed for electrolytes and creatinine. Serum electrolytes were measured before and 24 hours after administration of diuretics. RESULTS Forty patients (20 in each group) were included in the study. The groups were similar in their baseline characteristics. Over the 24 h study period, patients in Group F + I, had a larger natriuresis (P = 0.01), chloride loss (P = 0.01) and kaliuresis (P = 0.047). Patients in Group F + I also had a greater 24 hour urinary creatinine clearance (P = 0.01). The 24 hour urine volume and fluid balance was similar between the groups. Patients in Group F had an increase in serum sodium (P = 0.04), while patients in Group F + I had a decrease in both serum chloride (P = 0.01) and peripheral oedema (P < 0.001) during the study duration. CONCLUSION In fluid overloaded ICU patients, addition of indapamide to frusemide led to a greater natriuresis and creatinine clearance. Such a strategy might be utilised in optimising sodium balance in ICU patients.

Healthcare costs and outcomes for patients undergoing tracheostomy in an Australian tertiary level referral hospital

Objective Patients undergoing tracheostomy represent a unique cohort, as often they have prolonged hospital stay, require multi-disciplinary, resource-intensive care, and may have poor outcomes. Currently, there is a lack of data around overall healthcare cost for these patients and their outcomes in terms of morbidity and mortality. The objective of the study was to estimate healthcare costs and outcomes associated in tracheostomy patients at a tertiary level hospital in South Australia. Design Retrospective review of prospectively collected data in patients who underwent tracheostomy between July 2009 and May 2015. Methods Overall healthcare-associated costs, length of mechanical ventilation, length of intensive care unit stay, and mortality rates were assessed. Results A total of 454 patients with tracheostomies were examined. Majority of the tracheostomies (n = 386 (85%)) were performed in intensive care unit patients, predominantly using bedside percutaneous approach (85%). The median length of hospital stay was 44 (29–63) days and the in-hospital mortality rate was 20%. Overall total cost of managing a patient with tracheostomy was median

Inadvertent sodium loading in critically ill patients

192,184 (inter-quartile range

Conventional coagulation and thromboelastograph parameters and longevity of continuous renal replacement circuits

122560–

Acute cardiogenic pulmonary edema

295553); mean 225,200 (range

Therapeutic plasma exchange does not reduce vasopressor requirement in severe acute liver failure: a retrospective case series

5942–