White lung with milky effusion.

Thoracic duct injury is a rare complication of dorsal spine operations. Ultrasound chest plays an important tool for rapid diagnosis of acute dyspnea, drainage of massive effusion, and daily follow-up. Conservative treatment of postoperative chylous with measures to decrease chylous formation can lead to a resolution of chylothorax.

The Forgotten Hemodynamic (PCO2 Gap) in Severe Sepsis.

BACKGROUND: Central venous-arterial carbon dioxide difference (PCO2 gap) can be a marker of cardiac output adequacy in global metabolic conditions that are less affected by the impairment of oxygen extraction capacity. We investigated the relation between the PCO2 gap, serum lactate, and cardiac index (CI) and prognostic value on admission in relation to fluid administration in the early phases of resuscitation in sepsis. We also investigated the chest ultrasound pattern A or B. METHOD: We performed a prospective observational study and recruited 28 patients with severe sepsis and septic shock in a mixed ICU. We determined central venous PO2, PCO2, PCO2 gap, lactate, and CI at 0 and 6 hours after critical care unit (CCU) admission. The population was divided into two groups based on the PCO2 gap (cutoff value 0.8 kPa). RESULTS: The CI was significantly lower in the high PCO2 gap group (P=0.001). The high PCO2 gap group, on admission, required more administered fluid and vasopressors (P=0.01 and P=0.009, respectively). There was also a significant difference between the two groups for low mean pressure (P=0.01), central venous O2 (P=0.01), and lactate level (P=0.003). The mean arterial pressure was lower in the high PCO2 gap group, and the lactate level was higher, indicating global hypoperfusion. The hospital mortality rate for all patients was 24.5% (7/28). The in-hospital mortality rate was 20% (2/12) for the low gap group and 30% (5/16) for the high gap group; the odds ratio was 1.6 (95% CI 0.5-5.5; P=0.53). Patients with a persistent or rising PCO2 gap larger than 0.8 kPa at T = 6 and 12 hours had a higher mortality change (n = 6; in-hospital mortality was 21.4%) than patients with a PCO2 gap of less than 0.8 kPa at T = 6 (n = 1; in-hospital mortality was 3%); this odds ratio was 5.3 (95% CI 0.9-30.7; P=0.08). The PCO2 gap had no relation with the chest ultrasound pattern. CONCLUSION: The PCO2 gap is an important hemodynamic variable in the management of sepsis-induced circulatory failure. The PCO2 gap can be a marker of the adequacy of the cardiac output status in severe sepsis. A high PCO2 gap value (>0.8 kPa) can identify situations in which increasing CO can be attempted with fluid resuscitation in severe sepsis. The PCO2 gap carries an important prognostic value in severe sepsis.

Diagnostic accuracy of chest ultrasound in patients with pneumonia in the intensive care unit: A single-hospital study.

BACKGROUND AND AIMS: Chest radiography (CXR) and computerized tomography (CT) scan are the preferred methods for lung imaging in diagnosing pneumonia in the intensive care unit, in spite of their limitations. The aim of this study was to assess the performance of bedside lung ultrasound examination by a critical care physician, compared with CXR and chest CT, in the diagnosis of acute pneumonia in the ICU. MATERIALS AND METHODS: This was an observational, prospective, single-center study conducted in the intensive care unit of Ahmadi General Hospital. Lung ultrasound examinations (LUSs) were performed by trained critical care physicians, and a chest radiograph was interpreted by another critical care physician blinded to the LUS results. CT scans were obtained when clinically indicated by the senior physician. RESULTS: Out of 92 patients with suspected pneumonia, 73 (79.3%) were confirmed to have a diagnosis of pneumonia based on radiological reports, clinical progress, inflammatory markers, and microbiology studies. Of the 73 patients, 31 (42.5%) were male, with a mean age of 68.3 years, and a range of 27 to 94 years. Eleven (15%) patients had community-acquired pneumonia, and 62 (85%) had hospital-acquired pneumonia. In the group of patients with confirmed pneumonia, 72 (98.6%) had LUSs positive for consolidation (sensitivity 98.6%, 95% CI 92.60%-99.97%), and in the group without pneumonia, 16 (85%) had LUS negative for consolidation (specificity 84.2%, 95% CI 60.42%-96.62%), compared with 40 (55%) with CXRs positive for consolidation (sensitivity 54.8%, 95% CI 42.70%-66.48%) and 33 (45%) with CXRs negative for consolidation (specificity 63.16%, 95% CI 38.36%-83.71%).A chest CT was performed in 38 of the 92 enrolled patients and was diagnostic for pneumonia in 32 cases. LUSs were positive in 31 of 32 patients with CT-confirmed pneumonia (sensitivity 96%), and CXR was positive in 5 of 32 patients with CT-confirmed pneumonia (sensitivity 15.6%). CONCLUSION: Bedside lung ultrasound is a reliable and accurate tool that appears to be superior to CXR for diagnosing pneumonia in the ICU setting. LUS allows for a faster, non-invasive, and radiation-free method to diagnose pneumonia in the ICU.