Sigh in supine and prone position during acute respiratory distress syndrome

Interventions aimed at recruiting the lung of patients with acute respiratory distress syndrome (ARDS) are not uniformly effective. Because the prone position increases homogeneity of inflation of the lung, we reasoned that it might enhance its potential for recruitment. We ventilated 10 patients with early ARDS (PaO2/FIO2, 121 +/- 46 mm Hg; positive end-expiratory pressure, 14 +/- 3 cm H2O) in supine and prone, with and without the addition of three consecutive "sighs" per minute to recruit the lung. Inspired oxygen fraction, positive end-expiratory pressure, and minute ventilation were kept constant. Sighs increased PaO2 in both supine and prone (p < 0.01). The highest values of PaO2 (192 +/- 41 mm Hg) and end-expiratory lung volume (1840 +/- 790 ml) occurred with the addition of sighs in prone and remained significantly elevated 1 hour after discontinuation of the sighs. The increase in PaO2 associated with the sighs, both in supine and prone, correlated linearly with the respective increase of end-expiratory lung volume (r = 0.82, p < 0.001). We conclude that adding a recruitment maneuver such as cyclical sighs during ventilation in the prone position may provide optimal lung recruitment in the early stage of ARDS.     

Aspirin does not improve early arterial patency after streptokinase treatment for acute myocardial infarction.

OBJECTIVE--To investigate the hypothesis that the magnitude of the life saving effect of aspirin in the second international study of infarct survival (ISIS-2) trial cannot be explained solely by prevention of late reocclusion of the infarct related artery. The aim of this study was to discover whether or not aspirin in combination with streptokinase had an adjuvant thrombolytic effect. DESIGN--Aspirin (150 mg) or placebo was given at the start of streptokinase infusion to 200 patients seen within six hours of the start of prolonged ischaemic cardiac pain and ST segment elevation. All patients received active aspirin at three hours. Patency of the infarct related artery was assessed non-invasively by the normalised rise of creatine kinase activity at three hours after starting streptokinase in these 200 patients and in a further 52 patients who had already taken aspirin within one week of the start of infarction. MAIN OUTCOME MEASURE--Rise in creatine kinase activity from baseline to > or = 20% or < 20% of the peak rise of activity in blood taken at three hours after starting infusion of streptokinase. This correlates with patency or occlusion of the infarct related coronary artery at about 2.5 hours after starting streptokinase. RESULTS--Assessed in this way, patency of the infarct related artery was 60% in patients given aspirin, 63% in those given placebo, and 62% in patients who had already taken aspirin within one week of infarction. CONCLUSION--The magnitude of the life saving effect of aspirin remains unexplained. Further investigation is needed into the mechanism of action of antiplatelet treatment in relation to thrombolytic treatment.     

Acute and chronic effects of nicardipine on systolic and diastolic left ventricular performance in patients with heart failure: a pilot study

Nicardipine is a new calcium ion antagonist with vasodilating properties which has been shown to be effective in the treatment of hypertension and angina. We have studied its effect on systolic and diastolic left ventricular function in patients with mild to moderate degrees of congestive heart failure. Ten male patients with New York Heart Association Class II and III heart failure underwent acute treatment with an intravenous infusion of nicardipine (10 mg over 10 minutes). A nuclear probe was used to monitor left ventricular ejection fraction, peak filling rate, and relative cardiac output. Blood pressure and heart rate were also measured. The blood pressure (mean +/- SD) fell from 133 +/- 26/86 +/- 11 mmHg to 103 +/- 22/69 +/- 13; the heart rate rose from 67 +/- 9 beats/min to 85 +/- 10; left ventricular ejection fraction from 31 +/- 7 to 38 +/- 6%; relative cardiac output from 24 +/- 9 to 41 +/- 11; peak filling rate from 1.18 +/- 0.4 end-diastolic volume per second to 1.82 +/- 0.4 (p less than 0.001 in all cases) at the end of infusion. After 4 weeks of chronic treatment in eight patients (20 mg to be taken three times daily (tds) in one and 40 mg tds in 7), the blood pressure and heart rate had returned to baseline values but the improvements in left ventricular ejection fraction, relative cardiac output, and peak filling rate were sustained; this was associated with functional improvement in all 8 patients.(ABSTRACT TRUNCATED AT 250 WORDS)