Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial.

CONTEXT: Hypoxemia complicates the recovery of 30% to 50% of patients after abdominal surgery; endotracheal intubation and mechanical ventilation may be required in 8% to 10% of cases, increasing morbidity and mortality and prolonging intensive care unit and hospital stay. OBJECTIVE: To determine the effectiveness of continuous positive airway pressure compared with standard treatment in preventing the need for intubation and mechanical ventilation in patients who develop acute hypoxemia after elective major abdominal surgery. DESIGN AND SETTING: Randomized, controlled, unblinded study with concealed allocation conducted between June 2002 and November 2003 at 15 intensive care units of the Piedmont Intensive Care Units Network in Italy. PATIENTS: Consecutive patients who developed severe hypoxemia after major elective abdominal surgery. The trial was stopped for efficacy after 209 patients had been enrolled. INTERVENTIONS: Patients were randomly assigned to receive oxygen (n = 104) or oxygen plus continuous positive airway pressure (n = 105). MAIN OUTCOME MEASURES: The primary end point was incidence of endotracheal intubation; secondary end points were intensive care unit and hospital lengths of stay, incidence of pneumonia, infection and sepsis, and hospital mortality. RESULTS: Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). CONCLUSION: Continuous positive airway pressure may decrease the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery.

Regional citrate anticoagulation in critically ill patients treated with plasma filtration and adsorption.

BACKGROUND: In high-risk bleeding conditions conventional systemic anticoagulation with heparin is a contraindication to renal replacement therapy. We evaluate the feasibility and safety of regional citrate anticoagulation in high-risk bleeding conditions during coupled plasma filtration adsorption (CPFA). METHODS: Thirteen critically ill patients (9 severely burned, 4 polytraumas) with septic shock and acute renal failure treated with CPFA-CVVHD by using bicarbonate-based solutions (heparin-CPFA group, 58 sessions) or with CPFA-CVVHF using citrate (citrate-CPFA group, 36 sessions). RESULTS: Plasma flow and used cartridges showed no differences between the citrate-CPFA and heparin-CPFA groups, while lost clotted cartridges were significantly lower in the citrate-CPFA group. Blood ionized calcium (iCa2+), Ca2+ infusion, pH and bicarbonates remained constant during citrate-CPFA, with no difference between pre- and post-cartridge plasma citrate. A significant positive correlation between iCa2+ in blood and ultrafiltrate was present. CONCLUSIONS: These suits demonstrate the feasibility and safety of regional citrate anticoagulation in severely burned and polytrauma septic patients treated by CPFA.

Physiological effects of translaryngeal open ventilation in patients with restrictive respiratory disorders.

OBJECTIVE: To compare the efficacy of pressure-controlled ventilation (PCV) delivered through a conventional endotracheal tube with the same ventilatory mode using a small-size tube with the cuff left deflated (translaryngeal open ventilation: TLOV). SETTING: A medical-surgical intensive care unit (ICU). DESIGN: Prospective physiological study. PATIENTS: Thirteen consecutive patients with restrictive neuromuscular and thoracic respiratory disorders ventilated in pressure-controlled mode. INTERVENTIONS: The standard tube was removed and a microlaryngeal tube (i.d. 4 mm, o.d. 6 mm, length 380 mm) was inserted with the cuff left deflated. PCV was increased to match the tracheal pressure measured during conventional ventilation. Arterial blood gases were measured before, 1 h and 20 h after initiating TLOV. A patient comfort score was measured by a visual analogue scale during conventional ventilation and 20 h after initiating TLOV (0= very bad, 1= bad, 2= quite bad, 3= sufficient, 4= good, and 5= very good). RESULTS: Inspiratory pressure was significantly increased from 16+/-5 cmH(2)O to 68+/-13 cmH(2)O after 1 h and to 65+/-12 cmH(2)O after 20 h to match the tracheal pressure measured during conventional ventilation (CV) (p<0.005). No statistically significant differences were found in arterial blood gases and patient's respiratory rate before and after 1 and 20 h of TLOV. The comfort score was 1.3+/-0.4 and 3.6+/-0.4 during CV and TLOV, respectively, on a scale from 0 to 5 (p<0.002). CONCLUSION: This study indicates that, in selected patients, TLOV was as efficient as conventional PCV.