Chest
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Randomized Controlled Trial Comparative Study Clinical Trial
Treatment of multiple rib fractures. Randomized controlled trial comparing ventilatory with nonventilatory management.
We studied the treatment of multiple rib fractures in NIC, comparing ventilatory with nonventilatory methods in 69 patients who were randomly allocated to one of the following two treatments: (1) a CPAP mask combined with regional analgesia (n = 36); or (2) endotracheal intubation and mechanical ventilation with PEEP (n = 33). Clinical outcome was as follows: mean duration of treatment, 4.5 +/- 2.3 days for the group with CPAP and 7.3 +/- 3.7 days for the intubated group (p = 0.0003); mean number of days spent in intensive care, 5.3 +/- 2.9 days and 9.5 +/- 4.4 days, respectively (p = less than 0.0001); mean period of hospitalization, 8.4 +/- 7.1 days and 14.6 +/- 8.6 days, respectively (p = 0.0019); and patients developing complications: 28 percent (10/36) and 73 percent (24/33), respectively. Infections caused the difference in complications, primarily pneumonias, which occurred in 14 percent (5/36) of the group with CPAP but in 48 percent (16/33) of the intubated group. We conclude that treatment with a CPAP mask combined with regional analgesia can shorten and simplify treatment in these patients, mainly through a decreased infection rate, when compared with intubation and mechanical ventilation, and we recommend this treatment in patients similar to our sample.
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One hundred seven acutely ill ventilated patients were prospectively studied to ascertain the severity and frequency of alterations in gas exchange and hemodynamic parameters during brief bronchoscopy. Sedation was performed using midazolam (0.1 mg/kg IV) without topical anesthesia. An average decline in PaO2 of 26 percent was observed at the end of the procedure, compared to the baseline value, and this was associated with a mild increase in PaCO2 in spite of the use of a special adapter. ⋯ Fourteen patients developed hypoxemia of less than 60 mm Hg on FIO2 adjusted to 0.8. Of the ten risk factors univariately associated with hypoxemia, only the presence of ARDS (p less than 0.001) and "fighting" the ventilator during the procedure (p less than 0.05) remained significant after stepwise logistic regression. Attempts to prevent hypoxemia in critically ill patients should focus on inducing complete sedation, with careful attention to hemodynamic status, or providing maximal levels of oxygen to the ventilator (or both).
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Comparative Study
Agreement between noninvasive oximetric values for oxygen saturation.
We made an assessment of five pulse oximeters in regard to their ability to replace the HP ear oximeter as a noninvasive measurement of SaO2. Trials were performed during isocapnic progressive hypoxia (SaO2 range, 99 to 70 percent) in 22 white and six black subjects. Comparisons between values of SaO2 by oximetry were analyzed by comparing the difference of values by the two methods against their mean. ⋯ The distribution of differences between pulse oximeters and the HP were larger below 80 percent than above 85 percent. We conclude that pulse oximeters give higher values than the HP, a tendency which is more pronounced in black than in white subjects. While the limits of agreement are better at saturations above 85 percent, the 95 percent confidence limits of agreement between pulse oximeters and the HP are rather large (+/- 10 percent) and unacceptable for assuming that pulse oximeters will provide the same values as found in clinical studies using the HP.
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We present a patient who had chronic, bilateral pleural effusions without evidence of parenchymal, retrocardiac or mediastinal masses. A CAT scan of the abdomen and chest revealed the extension of a large abdominal pseudocyst through the diaphragm into the posterior mediastinum. The pseudocyst resolved with conservative management.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Role of aspirin with thrombolytic therapy in acute myocardial infarction.
Thrombolytic therapy has been shown to limit infarct size, improve ventricular function, and decrease mortality in suspected evolving myocardial infarction (MI). Aspirin therapy also decreases mortality as well as stroke and reinfarction in suspected evolving MI. ⋯ The use of aspirin with thrombolysis also protects against the increase in reinfarction observed when thrombolytic therapy is given alone. While ongoing research is evaluating the optimal thrombolytic agent as well as the possible role of heparin, it is already clear that the use of aspirin with thrombolytic therapy will significantly decrease reinfarction, stroke, and vascular mortality in suspected evolving MI.