prognostic value of alveolar recruitment strategy during the intra and postoperative periods in off pump coronary artery bypass surgery

In Off Pump Coronary Artery Bypass [OPCAB] surgery, there is a high incidence of deterioration in lung mechanics and arterial oxygenation. This study aimed at assessing the effect of alveolar recruitment on lung mechanics and oxygenation in patients undergoing OPCAB surgery. In this study, we performed a randomized controlled trial between 2 groups of patients undergoing OPCAB surgery. Group A: patients received a PEEP of 5 cm H20 only. Group 3: Alveolar Recruitment Strategy [ARS] was applied after finishing the proximal anastomotic procedure and repeated in the postoperative period in the ICU. The ARS consisted of raising the peak inspiratory Pressure [PIP] to 30 cm H20 and setting PEEP at 10 cm H20 and maintaining them for 1 minute. Then, both PIP and PEEP were increased to 40 and 15 cm H20 respectively and maintained for another minute. After arrival to the ICU, all patients received 5 cm H20 PEEP, then after 1 hour, the patients received either PEEP only or with the same previous strategy as in O.R. to their groups. In the OR, lung compliance as well as arterial oxygenation were measured after induction of anesthesia, before, and after setting both PEEP and ARS. In the ICU, arterial oxygenation was measured before both PEEP and ARS, as well as one and four hours later. Postoperative pulmonary complications including hypoxemia, hypercapnia, atelectasis, prolonged intubation, pulmonary congestion, pulmonary infection, total ICU stay and mortality werq recorded. There was a significant rise in lung compliance and arterial oxygenation in the ARS [Group B] than in the PEEP group [Group A]. As regards the Arterial Oxygen Tension, there was a continuous statistically significant rise in group B than in group A, 30 minutes after starting the ARS in the OR, before starting the ARS in the ICU, 30 minutes, 1 and 4 hours later [206.5 +/- 23.9,192.2 +/- 23.5, 250.7 +/- 31.9, 211.9 +/- 21.3 mmHg and 195.3 +/- 24.5 mm/Hg respectively in group B versus 126.9 +/- 10.1, 128.7111.6, 129.1 +/- 10.4, 129.8 +/- 9.4 mmHg and 130.1 +/- 9.7 mm/Hg respectively in group A] [P< 0.0001]. Additionally, there was a marked reduction in the postoperative hypoxemia, hypercarnia, atelectasis, prolonged intubation, infection and prolonged ICU stay in the ARS group. OPCAB patients in whom there is a reduction in lung compliance owing to the large volumes of intravenous fluids and compression of the right chest by the rotated heart during revascularization of the postero-lateral coronary vessels, applying an ARS in those patients greatly improves lung mechanics and arterial oxygen tension

Critical illness in obstetric patients requiring ICU admission: analysis of disease spectrum, interventions and clinical outcome

Critically ill obstetric patients represent an interesting group with unique characteristics, whose management is challenged by the presence of a fetus, an altered maternal physiology, and diseases specific to pregnancy. To review a series of critically ill obstetric patients admitted to our medical-surgical intensive care unit [ICU] to assess the spectrum of disease, required interventions, and maternal mortality, and to identify conditions associated with maternal death. This retrospectively designed cohort study comprised 365 patients [age, 26 +/- 8 years; mean gesta-tional age, 29 +/- 9 weeks] [mean +/- SD], constituting 2.8% of 13,000 ICU admissions. APACHE II score was 13 +/- 7, with 23% predicted mortality; SOFA score was 5 +/- 3; and TISS score at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation. ARDS, shock, and organ dysfunction were present in 18.6%, 27%, and 49% of patients, respectively. Most patients [63%] were admitted postpartum, and 75% of admissions were of obstetric cause. Hypertensive disease [40%], major hemorrhage [17%], septic abortion [13.7%], and non-obstetric sepsis [13.2%] were the principal diagnoses. Maternal mortality was 11.5%, with multiple organ dysfunction syndrome [43%] and intracranial hemorrhage [38%] as main causes. There were no differences in death rate in patients admitted for obstetric and non-obstetric causes. Only 32% of patients received antenatal care, which was more frequent in survivors [33% Vs 6% non-survivors, p=0.014]. Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients