Chest
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To assess the consequences of unplanned extubation (UE) in the ICU. ⋯ UE was associated with increased hospital and ICU LOS but decreased mortality in this heterogeneous population of critically ill adult patients. These findings were entirely explained by the divergent outcomes of the UE R+ and UE R- groups. Patients with UE who did not require reintubation had remarkably good outcomes. It remains incumbent on ICU teams to institute protocols for regular identification of patients ready to be liberated from MV.
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A comprehensive evidence review was conducted of the medical literature regarding the relationship between intraoperative interventions and the incidence of postoperative atrial arrhythmias, including, most commonly, atrial fibrillation (AF). Fifteen randomized, controlled studies and one large-scale concurrent cohort study were identified that reported on the following issues: systemic temperature during surgery (one report); "beating heart" surgery vs conventional bypass surgery (three reports); type of myocardial protection (five reports); the use of adjunctive posterior pericardiotomy (one report); the use of thoracic epidural anesthesia (TEA) [two reports]; the use of glucose-insulin-potassium (GIK) solutions (two reports); and the use of heparin-coated circuits for cardiopulmonary bypass (CPB) [two reports]. Based on a systematic review of the reported data and an analysis of the quality of the reported data, we recommend the following: (1) that mild hypothermia, rather than moderate hypothermia, may be effective in reducing the frequency of postoperative AF; (2) the use of posterior pericardiotomy may be a useful adjunct to reduce the frequency of postoperative AF; and (3) the use of heparin-coated CPB circuits is associated with less postoperative AF. Because of conflicting or inadequate data, we cannot conclude that the frequency of postoperative AF is affected by (1) the use of beating-heart techniques, (2) the type of myocardial protection strategy used, (3) the use of TEA, or (4) the use of GIK solutions perioperatively.
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We undertook the present study to investigate the perception of dyspnea (with respect to changes in end-inspiratory and end-expiratory lung volumes), during four different levels of high-intensity constant work rate exercise (CWRE) in patients with severe COPD. ⋯ In COPD subjects with flow limitation at rest, the perception of dyspnea increased nonlinearly with the magnitude of high-intensity CWRE in association with a faster respiratory pattern and an increase in EELV. At the highest work rates, it appeared that a reduction in tidal volume and ventilation peak may have limited the tolerance to exercise.
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The measurement of extravascular lung water index by double indicator (EVLWIdi) or the measurement of extravascular lung water index by transpulmonary thermodilution (EVLWItt) could be useful after pneumonectomy. Since pulmonary blood flow and volume are altered after pneumonectomy, the validity of these methods is uncertain. This study has compared measurements of EVLWIdi and EVLWItt with measurement of extravascular lung water index by gravimetry (EVLWIg) in a porcine model of pulmonary edema induced after right pneumonectomy. ⋯ Double-indicator and transpulmonary thermodilution methods could be useful in monitoring extravascular lung water index (EVLWI) after pneumonectomy, but transpulmonary thermodilution largely overestimates EVLWI.
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Atrial fibrillation (AF) and atrial flutter (AFL) are arrhythmias that commonly occur following cardiac surgery. The precipitating events are not always obvious, although predisposing factors including age have been defined. Postoperative AF and AFL add significantly to both the cost and morbidity of cardiac surgery. ⋯ Specific issues addressed include the following: (1) controlling the ventricular response rate in the patient with postoperative AF and AFL; (2) preventing thromboembolism in the setting of AF and AFL including the appropriate role of anticoagulation therapy; (3) pharmacologic approaches to converting AF or AFL to normal sinus rhythm, and maintaining normal sinus rhythm postoperatively; and (4) pharmacologic and surgical prophylaxis against postoperative AF and AFL. The resulting clinical practice guidelines represent the best-supported treatments, based on a rational scientific approach formulated from randomized clinical trials and systematic reviews. The panel convened by the Health and Sciences Policy Committee of the ACCP reviewed the currently available evidence to provide a basis for making specific recommendations for patient care.