Hospital practice (1995)
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Hospital practice (1995) · Feb 2010
Case ReportsPulmonary embolism with unexpected echocardiogram findings.
A 56-year-old woman was evaluated for dyspnea in the emergency department. She had no risk factors for venous thromboembolism except hormone replacement therapy; however, pulmonary embolism was suspected and subsequently confirmed via computed tomographic angiogram. An echocardiogram was conducted to further assess right ventricular function, revealing marked right ventricular enlargement and a mobile mass in the left atrium (initially suspected to be an atrial myxoma). ⋯ A repeat echocardiogram showed resolution. This case highlights that although echocardiography can be helpful in risk stratification when assessing patients with pulmonary embolism, unexpected findings may be encountered. When clinicians identify multiple clinical findings, Occam's razor suggests that these multiple findings are most likely related.
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Aspiration pneumonia and pneumonitis are common clinical syndromes that occur in hospitalized patients. Aspiration pneumonia occurs in patients with dysphagia and usually presents as a community-acquired pneumonia with a focal infiltrate in a dependent bronchopulmonary segment. ⋯ Aspiration pneumonitis follows the aspiration of gastric contents, usually in patients with a marked decreased level of consciousness. Treatment of aspiration pneumonitis is essentially supportive; however, corticosteroids and other immunomodulating agents may have a role in these patients.
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Hospital practice (1995) · Feb 2010
ReviewMethicillin-resistant Staphylococcus aureus in community-acquired and health care-associated pneumonia: incidence, diagnosis, and treatment options.
Pneumonia is one of the leading causes of death in the United States. As health care has expanded into community settings, including outpatient clinics, long-term care facilities, and dialysis centers, a new category of pneumonia-health care-associated pneumonia (HCAP)-has been defined. Bacterial resistance to antibiotics is rising among community-acquired infections, and the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) infections, particularly the severe form of necrotizing pneumonia mediated by USA 300 in young and healthy individuals, warrants attention. ⋯ The spread of resistant pathogens in the community challenges currently available antimicrobial agents for effective treatment of MRSA-mediated pneumonia. Approval of newer antimicrobials with MRSA activity may provide additional options for the management of pneumonia. This article provides a review of the role of MRSA as a causative pathogen in CAP and HCAP.
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Hospital practice (1995) · Feb 2010
ReviewNoninvasive ventilation in adults with acute respiratory distress: a primer for the clinician.
Noninvasive ventilation (NIV) has become an integral part of critical care management. Despite > 2 decades of experience, it is relatively underused, with general utilization reported as a little over 10% in a recent international survey. Lack of training, knowledge, equipment, and experience with NIV may account for its slow adoption. ⋯ Patients with acute respiratory failure due to chronic obstructive pulmonary disease or congestive heart failure are ideal candidates for NIV, and optimal efficacy in associated conditions is often linked to these 2 conditions. Technical issues and written guidelines are addressed, including details of an adequate trial of therapy as well as criteria for intubation. Attention to these elements should increase the success rate of NIV, which in turn should increase its general use.
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The definition of septic shock includes sepsis-induced hypotension despite adequate fluid resuscitation, along with the presence of organ perfusion abnormalities, and ultimately cell dysfunction. To restore adequate organ perfusion and cell homeostasis, cardiac output should be restored with volume infusion plus vasopressor agents as indicated. Appropriate arterial pressure for each individual patient and proper arterial oxygen content are key elements to restoring perfusion. ⋯ The Surviving Sepsis Campaign guidelines refer to either norepinephrine or dopamine as the first-choice vasopressor agent to correct hypotension in septic shock. However, recent data from observational and controlled trials have challenged these recommendations concerning different adrenergic agents. As a result, our view on the prescription of vasopressors has changed from a probably oversimplified "one-size-fits-all" approach to a multimodal approach in vasopressor selection.