The Yale journal of biology and medicine
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Twenty years have now elapsed since Ashbaugh and Petty first described the syndrome of acute respiratory failure associated with a wide spectrum of clinical conditions. During the past two decades, significant advances have emerged in our understanding of the clinical conditions associated with the syndrome and the pathophysiological changes affecting the alveolar-capillary membrane responsible for the characteristic non-cardiogenic pulmonary edema. Recent data have reaffirmed the notion that mortality rates in ARDS remain in excess of 60 percent, essentially unchanged since the first description of the syndrome, despite all the advances in critical care medicine in the intervening years. ⋯ The persistently high mortality rates of 60-70 percent in patients with established ARDS have provoked recurring interest in new techniques of providing mechanical ventilation. Most studies have shown, however, that mortality in ARDS patients is attributable mainly to sepsis and multi-system organ failure rather than primarily to respiratory failure. Established and speculative intervention to reduce sepsis and multi-system organ failure associated with ARDS will be featured in the review.
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Review Comparative Study
Transesophageal two-dimensional echocardiography in the critically ill--is the Swan-Ganz catheter redundant?
Swan-Ganz catheterization can facilitate intra-operative management of critically ill patients. The derived data lacks specificity, however, and, as such, is frequently misleading. This disadvantage, combined with recent advances in echocardiography imaging techniques, has resulted in increasing application of transesophageal (TE) two-dimensional echocardiography (2D-echo) to supplement and, in instances, to supplant conventional cardiac monitoring. ⋯ In contrast, corresponding estimates of LV ejection fraction correlate closely with overall performance, at least in cases without asynergy. Finally, the capacity of TE 2D-echo to detect LV regional wall-motion abnormalities can be particularly useful. Such abnormalities commonly represent early manifestations of ischemia and can, in addition, be predictive of subsequent outcome.
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Until recently, the clinical significance of post-surgical pain and its undertreatment were for the most part unappreciated. Recognition that inadequate analgesia adversely affects the patient's cardiovascular, pulmonary, and emotional status has spurred development of new and highly effective methods of controlling pain. With the introduction of spinal opioid and patient-controlled analgesia (PCA) came the realization that, while such forms of therapy provided superior pain relief, they were not without their own unique and occasionally serious side effects. ⋯ Interpleural analgesia represents an important therapeutic option in patients sensitive to opioid-induced respiratory depression. The technique is more effective when local anesthetic solutions are continually infused. Analgesic efficacy may be further enhanced by the addition of "low-dose" PCA.
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Acquired immune deficiency syndrome (AIDS), a devastating disease with numerous masks (e.g., a primary neurosymptomatic disease), has now been reported in over one hundred countries of the world. Projections by the Public Health Service of the numbers of cases and fatal illnesses in the United States by 1991 stagger the imagination, and we are told that these projections may be understated. The Veterans Administration (VA) has not been immune to this disorder, over 2,000 cases of frank AIDS (as defined by the Centers for Disease Control [CDC] having been reported to VA's Central Office by 111 of the VA's 172 medical centers. ⋯ The VA has developed an action plan, one of whose features is the development of a direct discussion and collaboration with other federal health care agencies, including the military. Emphasis is to be placed on the exchange of information among these various executive branches and, most important, on the smooth transfer of patients with AIDS or ARC from the uniformed services into the VA's health care system. In addition to the primary goal of providing timely, compassionate care to these patients, the VA also has a commitment to the dissemination of information to our patients, their families, and our employees.
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The adult respiratory distress syndrome (ARDS) represents a common denominator of acute lung injury leading to alveolar flooding, decreased lung compliance, and altered gas transport. In the absence of specific etiology and therapy, the management of ARDS remains largely supportive. Ubiquitous use of intermittent positive-pressure ventilation with positive end-expiratory pressure (PEEP) improves arterial oxygenation but with some risk of pulmonary barotrauma and decreased cardiac output. The recent understanding of lung inflation as a modulator of right heart afterload and the effect of the right ventricle on global cardiac performance continues to redefine optimal patterns of ventilatory and hemodynamic intervention in ARDS.