Chest
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While the outcome of in-hospital cardiopulmonary arrest has been studied extensively, the clinical antecedents of arrest are less well defined. We studied a group of consecutive general hospital ward patients developing cardiopulmonary arrest. Prospectively determined definitions of underlying pathophysiology, severity of underlying disease, patient complaints, and clinical observations were used to determine common clinical features. ⋯ Their underlying diseases are generally not rapidly fatal. Arrest is frequently preceded by a clinical deterioration involving either respiratory or mental function. These features and the high mortality associated with arrest suggest that efforts to predict and prevent arrest might prove beneficial.
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We treated a coronary artery bypass patient whose postoperative course was complicated by heparin-induced thrombocytopenia and resultant pulmonary artery and saphenous vein graft thromboses. The pulmonary thromboemboli were found first, and pulmonary blood flow was restored with intravenously administered tissue plasminogen activator (tPA). ⋯ We conclude that heparin-induced thromboses in the pulmonary arteries are amenable to thrombolytic therapy, including tPA, whereas this regimen appears to have little effect on saphenous vein grafts. We also found that a combination of warfarin and thrombolytic therapy is an alternative regimen for heparin-intolerant patients who require PTCA.
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To determine the magnitude, duration, and associated factors of perioperative changes in pulmonary function, we retrospectively reviewed the medical records of 145 patients who required preoperative mechanical ventilation for acute respiratory failure before undergoing 200 surgical procedures. Patients were grouped into five pulmonary diagnostic categories: (1) adult respiratory distress syndrome (ARDS) (n = 49); (2) pneumonia (n = 20); (3) atelectasis (n = 65); (4) congestive heart failure (n = 11); and (5) acute ventilatory failure (n = 55). Sixty patients underwent intra-abdominal surgery, 135 patients required surgery on the periphery, and five patients had a thoracotomy. ⋯ Within the first several hours postoperatively, PaO2/FIO2 recovered to preoperative levels in all patients, even in those who had severe intraoperative hypoxemia develop and who underwent laparotomy. We conclude that most patients with acute respiratory failure receiving preoperative mechanical ventilation experienced mild-to-moderate deterioration in intraoperative pulmonary oxygen exchange that rapidly returned to preoperative levels after surgery. We recommend that necessary surgery not be postponed by concern that pulmonary function will be worsened by surgery and anesthesia.
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Comparative Study
Cardiorespiratory effects of pressure controlled ventilation in severe respiratory failure.
Cardiorespiratory values were measured in ten patients with severe respiratory failure on volume controlled and pressure controlled ventilation. Tidal volume, respirator rate, PEEP, auto-PEEP, inspiratory:expiratory ratio (1:2) and FIo2 were maintained at the same value for both ventilatory modalities. ⋯ There were no significant changes in other cardiorespiratory values, such as arterial blood pressure, nor in ventilatory measurements, such as mean airway pressure, associated with the use of PCV. These results suggest that PCV may be a beneficial ventilatory modality in the treatment of severe respiratory failure since it results in improvement in arterial oxygenation, tissue oxygen delivery and utilization without any concomitant adverse effects on other hemodynamic or ventilatory factors.
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Mediastinal and subcutaneous emphysema have been reported as a consequence of deliberate manipulations of the breathing pattern producing a Valsalva-like maneuver in healthy subjects. We present a case of pneumomediastinum, pneumothorax and subcutaneous emphysema occurring in a normal volunteer after repeated measurements of the PEmax.