Chest
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Pulmonary alveolar proteinosis (PAP) is characterized by accumulation of large quantities of lipoproteinaceous materials in alveoli. Surfactant protein A (SP-A) is the predominant phospholipid-associated glycoprotein in pulmonary surfactant and is specific to the lung. ⋯ The ratio of SP-A to protein in BAL fluid of PAP was at almost the same level as in normal subjects, while the ratio of SP-A to phospholipid in PAP was significantly higher. These results indicate that measurement of BAL fluid SP-A is of clinical value for diagnosis of PAP and should be used as a biochemical diagnostic tool in the clinical laboratory.
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Randomized Controlled Trial Comparative Study Clinical Trial
Propofol vs midazolam in short-, medium-, and long-term sedation of critically ill patients. A cost-benefit analysis.
The purpose of this study was to evaluate and compare the clinical effects, safety, and economic cost of propofol and midazolam in the sedation of patients undergoing mechanical ventilation in the ICU. Eighty-eight critically ill patients were studied and randomly allocated to receive short-term (less than 24 h), medium-term (24 h to 7 days), and prolonged (more than 7 days) continuous sedation with propofol (n = 46) or midazolam (n = 42). Mean doses required were 2.36 mg/kg/h for propofol and 0.17 mg/kg/h for midazolam. ⋯ Recovery of total consciousness was predictable according to sedation time in propofol-treated subgroups (r = 0.98, 0.88, and 0.92, respectively), while this correlation was not observed in the midazolam-treated group. In the subgroup with sedation of less than 24 h, propofol provided a cost savings of approximately 2,000 pesetas (pts) per patient, due to shorter stays in the ICU. We conclude that propofol is a sedative agent with the same safety, higher clinical effectiveness, and a better cost-benefit ratio than midazolam in the continuous sedation of critically ill patients.
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Randomized Controlled Trial Clinical Trial
Lack of efficacy of intrapleural bupivacaine for postoperative analgesia following thoracotomy.
Intrapleural bupivacaine has been reported to be effective for analgesia following cholecystectomy and thoracic surgery. Twenty patients who had a posterolateral thoracotomy were studied in a randomized, double-blind, placebo-controlled fashion. Patients were assigned to receive intrapleural administration of either 0.5 percent bupivacaine or saline solution every 4 h for 12 doses postoperatively, as well as narcotic analgesics as needed for additional pain control. ⋯ Two patients who received bupivacaine and three patients who received placebo had development of pneumonia or atelectasis postoperatively. There was no statistically significant difference in any parameter between those who received bupivacaine and those who received placebo. Thus, there was no subjective or objective clinical benefit of this method of postoperative analgesia compared with placebo following posterolateral thoracotomy.
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The mechanisms of impaired arterial oxygenation that occur in certain patients with chronic liver cirrhosis are still debated. In the present study, we investigated nine cirrhotic patients with severe respiratory disability (mean PaO2, 64 +/- 5 mm Hg), using the inert gas elimination technique to assess the distribution of ventilation-perfusion (VA/Q) ratios. We also determined shunt fraction during pure oxygen breathing, both in supine and sitting positions. ⋯ Indomethacin did not improve gas exchange or VA/Q distribution and did not affect systemic or pulmonary hemodynamics. The results show that in cirrhotic patients with severe respiratory disability, intrapulmonary shunting is the main determinant of impaired gas exchange, with no evidence of a defect in oxygen diffusion or an extrapulmonary shunt. Vasodilating prostaglandins do not appear to contribute to these alterations.
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Neopterin (N), a marker for activated cell-mediated immunity, was assayed in the sera of 44 lung recipients early and late after transplantation. The study was a prospective, blind clinical trial designed to evaluate the following: (1) the daily dynamics of the serum neopterin/creatinine (N/C) ratio during the first 3 weeks after transplantation; (2) the correlation between changes in the serum N/C ratio and episodes of rejection or infection; (3) the correlation between the serum N/C ratio and the concentration of serum soluble interleukin 2 receptor (sIL-2R), a marker of T-cell activation; and (4) the potential value of monitoring the serum N/C ratio during noninvasive long-term follow-up of lung recipients. ⋯ Our results indicate that more than 3 weeks after transplantation, the serum N/C ratio increases only in cases of infection, mostly CMV pneumonia. In contrast, both rejection and infectious complications are associated with an increased N production in the early postoperative period.