Effect of airway pressure display on interobserver agreement in the assessment of vascular pressures in patients with acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Previous investigations have identified significant interobserver variability in the measurements of central venous pressure and pulmonary artery occlusion pressure in critically ill patients. Large interobserver variability in the measurement of vascular pressures could potentially lead to inappropriate treatment decisions. OBJECTIVE: We postulated that adding an airway pressure signal (Paw) to pressure tracings of central venous pressure and pulmonary artery occlusion pressure would improve interobserver agreement by facilitating identification of end-expiration. DESIGN: To test this hypothesis, six independent experts used a standard protocol to interpret strip-chart recordings of central venous pressure and pulmonary artery occlusion pressure with or without Paw. Two observers were said to agree if their measurements were within 2 mm Hg of each other. SETTING/SUBJECTS/INTERVENTIONS: A total of 459 strip-chart recordings (303 without Paw and 156 with Paw) were obtained from 121 patients enrolled in the ARDSnet Fluids and Catheters Treatment Trial (FACTT) in 16 different hospitals. RESULTS: Agreement within 2 mm Hg between two measurements was 79% for central venous pressure strips without Paw vs. 86% with Paw. For pulmonary artery occlusion pressure, agreement increased from 71% without Paw to 83% with Paw. The increase in agreement with the addition of Paw was greater for strips demonstrating >8 mm Hg phasic respiratory variation compared with strips demonstrating less phasic respiratory variation. CONCLUSION: Paw display is a simple, inexpensive method to facilitate the identification of end-expiration that can significantly improve interobserver agreement.

Underappreciation of sleep disorders as a cause of motor vehicle crashes.

Despite an increased risk of motor vehicle crashes (MVC) in patients with obstructive sleep apnea (OSA), we hypothesized that OSA was not considered in drivers admitted to trauma centers after an injury-producing MVC. A retrospective study on drivers involved in MVCs admitted to a level 1 trauma center was performed, with crash cause determined and the frequency of sleep studies recorded. A questionnaire was also mailed to 240 trauma centers seeking information on evaluation of patients with unexplained causes for MVCs, including screening for OSA. There were 122 drivers of MVCs admitted to our hospital, 60/122 (49%) had unexplained crashes and no sleep studies were performed. There were 70 survey respondents (30% return rate), 35/70 (50%) centers routinely screened for syncope after unexplained MVC, however, no center screened for OSA. US trauma centers do not screen for sleep disorders despite the associated increased crash risk and the high prevalence of crashes that can not be explained by other causes. We believe this reflects a lack of awareness of sleep disorders by health care professionals caring for trauma victims and education is of utmost importance.

Adenosine release into venous plasma during free flow exercise.

We measured adenosine release into venous plasma as an index of interstitial adenosine concentration during free flow exercise hyperemia. Isolated, blood-perfused dog calf muscles were stimulated at 6 Hz for 10 min at free flow. Plasma samples were collected before, during, and after the exercise period for analysis of plasma adenosine concentration [( ADO]) by HPLC. Adenosine release (Rado) was calculated as plasma flow times venous-arterial [ADO] difference. Rado (nmole/min/100 g) went from -0.1 +/- 0.1 at rest to 6.6 +/- 4.6 during 6-Hz exercise. Isoproterenol infusion, which caused an increase in blood flow equivalent to 6-Hz exercise, did not result in increased Rado. Infusion of the 5'-nucleotidase inhibitor, alpha, beta, methylene adenosine 5'-diphosphate (AOPCP) did not prevent the increase in Rado during exercise. These results support the hypothesis that interstitial adenosine concentration increases during sustained free flow twitch exercise and that this results in increased release of adenosine into venous plasma.