Clinics in chest medicine
-
Cardiac dysfunction is common in sepsis and septic shock. An understanding of this pathophysiology is crucial in treatment of this disorder. This article reviews the numerous studies of septic shock in humans that focus on cardiovascular physiology, briefly addresses the possible etiology, and concludes with therapeutic implications.
-
Hemodynamic support during sepsis should focus on aggressive resuscitation coupled with vasopressors aimed at restoration of blood pressure and end-organ perfusion and preservation. The choice of vasopressors should be based on the degree and persistence of peripheral vasodilatation as well as the degree of cardiac stimulation required. ⋯ Dopamine's role of renovascular preservation remains controversial. Therapeutic strategies aimed at supranormal improvements in cardiac index or oxygen delivery have no documented effect in septic patients and should not be part of their therapy.
-
The preoperative pulmonary evaluation of organ transplant candidates involves the diagnosis of unexplained pulmonary infiltrates or symptoms, interpretation of pulmonary function abnormalities, and an assessment of surgical risk. Pretransplant pulmonary considerations in patients with end-stage hepatic diseases relate primarily to hypoxemia from poorly understood intrapulmonary vascular dilatations, mechanical dysfunction, and states of increased extravascular lung water. Except in severe cases, however, these generally do not prohibit liver transplantation, and even are likely to improve after transplant surgery. ⋯ As immunosuppression begins to have an effect, the LTx recipient becomes susceptible to the same opportunistic infectious organisms (with their frequent pulmonary involvement) that cause significant morbidity and mortality in recipients of other solid organ transplants. Because many of the immunosuppressive agents also are the same, noninfectious side effects such as pulmonary edema and malignancy also are similar. As with all immunocompromised patients, prophylaxis, when possible, persistent infection surveillance, and an aggressive diagnostic and therapeutic approach help decrease the impact of pulmonary dysfunction in LTx recipients.
-
Clinics in chest medicine · Sep 1995
ReviewThoracoscopic management of malignant pleural effusions.
Thoracoscopy has been around for decades, advocated by some, but until recently, ignored by many. Not surprisingly, its diagnostic and therapeutic efficacy in patients with suspected or proven malignant pleural effusions has withstood the test of time. Today, the potential benefits of thoracoscopy must be weighed against its cost in patients with limited life expectancy. ⋯ Several studies demonstrate that thoracoscopic talc pleurodesis is more frequently successful than other methods of pleurodesis. As a staging procedure, thoracoscopy helps determine extent of disease, and possibly, prognosis in patients with metastatic pleural carcinomatosis, lung cancer, and malignant mesothelioma. As this procedure is increasingly rediscovered by our medical and surgical communities, greater clinical and experimental investigation aimed at establishing successful management strategies in patients with malignant pleural effusions will hopefully occur.