A protocolized approach to pulmonary failure and the role of intermittent prone positioning

INTRODUCTION: We present a series of adult patients treated under a protocol for severe lung failure (acute respiratory distress syndrome [ARDS]) that uses positive end-expiratory pressure (PEEP) optimization and intermittent prone positioning (IPP) to reduce shunt, improve oxygen (O(2)) delivery, and reduce FiO(2). METHODS: Trauma, emergency vascular, and general surgical patients with PaO(2)/FiO)(2) (PF) ratio < 200 were entered into a protocol designed to maintain mixed venous saturation (SVO(2)) > 70% with FiO(2) < 0.50. Therapy involved a sequential algorithmic approach that included pulmonary artery oximetry, "best-PEEP" determination, optimization of cardiac function, limitation of VO(2), transfusion to hematocrit of 35%, frequent bronchoscopy, rational diuresis and, if the FiO(2) was > 0.50, a trial of IPP with every-6-hour rotations. Unstable spine fractures and pelvic external fixators were the only contraindications to IPP. We collected data prospectively and from the charts and trauma registry. RESULTS: Forty adults were treated by protocol, 29 were injured and 11 had vascular or general surgical primary problems. The patients were 46.3 +/- 3.1 years old (the trauma patients were 42.9 +/- 3.2, and the vascular/general patients were 62 +/- 7.5 years old). Average Injury Severity Score was 25.9 +/- 3.7 and the Murray lung injury score was 2.65 +/- 0.9. IPP was used in all patients including those with recent tracheostomy, open abdomens, laparotomy, thoracotomy, leg external fixators, central nervous system injury, continuous venovenous hemofiltration and extracorporeal membrane oxygenation cannulae, vasopressor therapy, recent chest wall open reduction and internal fixation, and facial fractures. With the initiation of IPP therapy, the PF ratio increased from 132.1 +/- 8.5 to 231.6 +/- 14.2 (p < 0.001), the FiO(2) was decreased from 65.9 +/- 4.0% to 47.0 +/- 1.1% (p < 0.001), and the SVO(2) increased from 75.3 +/- 1.8% to 78.6 +/- 1.6% (p = 0.023). PEEP and static compliance were unchanged. The duration of IPP was 85.6 +/- 14.9 hours (median, 55 hours; range, 12 to 490 hours). Within 48 hours, all patients were on FiO(2) < or = 50. Mortality was 20% (14% for trauma) and none died of ARDS. The only complications of IPP were one case of partial-thickness skin loss from a malpositioned nasogastric tube and a case of transient lingual edema. CONCLUSION: IPP was independently responsible for an increase in PF ratio and SVO(2). We effectively and safely used IPP in our patients with ARDS, including many with issues generally considered to be contraindications. IPP and best-PEEP therapy enabled us to wean all of our patients' Fio2 to < or = 0.50 within 48 hours of ARDS onset.     

Dexmedetomidine,a promising drug

Surgical patients and others admitted to recovery and intensive care units require sedation and pain therapy, for which a range of pharmaceuticals is available. Their use is more or less widespread, but other drugs, such as dexmedetomidine, have been and continue to be studied for application in such patients. Dexmedetomidine, a compound derived from imidazole, has a high affinity for the alpha-2 adrenoreceptor, on which it acts as a potent agonist. A large number of laboratory and animal studies have been performed, as have clinical trials enrolling healthy volunteers or patients with the aim of shedding shed light on the main pharmacological features of dexmedetomidine. As a result, dexmedetomidine is known to have sedative, hypnotic and analgesic properties. It diminishes the need for other anesthetics and sympathicolytics, and it reduces catecholamine release. Controlled clinical trials have looked at the use of dexmedetomidine in patients who require sedation and analgesia in postoperative intensive care units. Research shows that dexmedetomidine lowers the need both for other sedatives, such as propofol or midazolam, and for analgesic morphine. Moreover, its effect on ventilation is scarce. Dexmedetomidine is presently distributed in the United States but not in the European Union. The aim of this review was to outline the main pharmacological properties of dexmedetomidine, including its pharmacokinetics and pharmacodynamics, to give an overall view of this promising drug.     

Clinical and pathological characteristics of oral lichen planus in hepatitis C-positive and -negative patients

The reported prevalence rate of anti-hepatitis C virus (HCV) antibodies in patients with oral lichen planus shows wide geographical variation and ranges from 0 to 65%. Certain characteristic clinical features have been attributed to oral lichen planus associated to HCV infection. The purpose of this investigation has been to assess hypothetical clinical differences, as well as differences in the intensity of the subepithelial inflammatory infiltrate between oral lichen planus-HCV +ve patients and oral lichen planus-HCV -ve patients. A total of sixty-two patients entered the study. Their mean age was 63.5 +/- 14.49 years, and 48.4% of them were men and 51.6% women. Patients were classified according to their serum HCV positivity. Age, sex, clinical presentation (reticular or atrophic-erosive), extension of the lesions, location of the lesions, number of locations affected, intensity of the inflammatory infiltrate and Candida albicans colonization were recorded for each patient. Reticular lichen planus was the most frequent clinical presentation in both HCV +ve (57.1%) and HCV -ve patients (63.6%). C. albicans colonization ranged from 42.8% in HCV +ve and 41.7% in HCV -ve patients. HCV + ve patients showed certain oral locations more frequently affected than HCV -ve ones: lip mucosa, 28.6% versus 7.3%; tongue, 57.1% versus 29.1%; and gingiva, 71.4% versus 23.6%. The number of affected intraoral locations was higher in HCV +ve patients (71.4%) than among HCV -ve ones (20.4%; chi2 = 8.34; P < 0.011). No statistically significant differences could be established in terms of density of subepithelial inflammatory infiltrate between the groups. Our results reinforce the need for liver examination in all patients with oral lichen planus, particularly those showing lesions on the gingiva with multiple intraoral locations affected, as no pathological differences could be identified between HCV + ve and HCV -ve patients.     

Immediate reconstruction after mastectomy for breast cancer does not prolong the time to starting adjuvant chemotherapy

BACKGROUND: Immediate breast reconstruction is often performed after mastectomy for breast cancer. There has been concern that this will result in a delay in initiating chemotherapy and, as a consequence, may adversely impact survival. In this study we sought to determine whether immediate breast reconstruction affects the interval between surgery and adjuvant chemotherapy. METHODS: A single institution retrospective analysis was made using the institutional tumor registry and chart reviews. RESULTS: Forty-nine patients were identified who had undergone mastectomy with immediate reconstruction followed by adjuvant chemotherapy. They were compared with 308 patients undergoing mastectomy without reconstruction. Patients who underwent reconstruction were overall younger (46 versus 55, P <0.001), and had more advanced disease. The time to chemotherapy was significantly longer in the group receiving no reconstruction: 53 versus 41 days (P = 0.039). The type of reconstruction did not affect the time to chemotherapy. CONCLUSIONS: Immediate reconstruction after mastectomy does not increase the time to chemotherapy compared with mastectomy alone.     

Venous compression ultrasonography of the lower limbs: a diagnostic tool in the hands of pneumologists

Our objective was to study agreement between the compression ultrasound images taken in our respiratory medicine department and the duplex ultrasound images obtained by radiologists at our hospital for patients admitted to our ward with suspected diagnoses of venous thromboembolism.Seventy-eight consecutive patients admitted to our respiratory medicine ward suspected of venous thromboembolism were enrolled. Both types of images were available for all patients studied. Agreement was 90% with a Kappa coefficient of 0.81. Agreement between the two techniques was good. Therefore, compression ultrasonography is a technique that can be handled by respiratory medicine specialists for the diagnosis of venous thromboembolism.