ABSTRACT
Pulmonary alveolar proteinosis (PAP) is a rare disorder in which lipoproteinaceous material is deposited in the alveoli, compromising gaseous exchange. We report the case of a 29-year-old female patient presenting with the most extreme case of PAP yet reported. She successfully managed by aggressive bilateral whole lung lavage (WLL) in a single sitting using extracorporeal membrane oxygenation (ECMO) support. Despite critical hypercarbia and ventilator-dependence for 12 days before lavage, the patient experienced rapid recovery of pulmonary function after WLL and ECMO could be discontinued on-table. Aggressive WLL with ECMO support can be safe and effective even in the most severe cases of PAP.
Subject(s)
Extracorporeal Membrane Oxygenation/methods , Pulmonary Alveolar Proteinosis/diagnosis , Pulmonary Alveolar Proteinosis/therapy , Adult , Bronchoalveolar Lavage/methods , Bronchoscopy , Disease Progression , Female , Fiber Optic Technology , Follow-Up Studies , Humans , Pulmonary Gas Exchange , Radiography, Thoracic , Respiration, Artificial/methods , Risk Assessment , Severity of Illness Index , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
STUDY OBJECTIVE: The use of different opioids for patient-controlled analgesia (PCA) may affect postoperative cognitive function differently. Patient-controlled analgesia fentanyl has been shown to preserve cognitive function better than morphine. The effect of PCA tramadol on cognitive function is unknown. This study aims to compare postoperative cognitive function and analgesia of PCA fentanyl or tramadol. DESIGN: Prospective randomized double-blinded study. SETTING: Metropolitan teaching hospital. PATIENTS: 30 ASA physical status I, II, and III patients undergoing lower abdominal operations. INTERVENTIONS: Patients received standard general anesthesia for their operations. Postoperatively, patients received either fentanyl (group F, 10 mug bolus, n = 17) or tramadol (group T, 20 mg bolus, n = 13) for PCA. Group F patients also received fentanyl boluses and group T patients received tramadol boluses intraoperatively. MEASUREMENTS: Cognitive function was measured using Mini-Mental State Examination and Benton Visual Retention Test (BVRT) preoperatively and on days 1 and 2. Pain was measured by numerical rating scale. RESULTS: No differences were found in postoperative Mini-Mental State Examination or BVRT scores, but significantly fewer (29.4%; 95% confidence interval [CI], 13.3%-53.1%) group F patients were able to complete BVRT compared with group T patients (84.6%; 95% CI, 57.8%-95.7%; 95% CI of difference, 19.4%-74.8%) (P = 0.010) on day 1. In the first 24 hours, group F and group T patients had similar analgesia at rest, but group T patients had better analgesia during cough (mean Numeric Rating Scale, 7.6; 95% CI, 7.0-8.2 vs 6.0; 95% CI, 4.8-7.2, group F vs group T) (P = 0.018; 95% CI of difference, 0.4-2.8). No differences were found in frequency of side effects or patient satisfaction. CONCLUSIONS: Tramadol or fentanyl PCA has similar cognitive effects on days 1 and 2; however, patients receiving tramadol PCA are more motivated to undergo cognitively demanding tasks and have slightly better analgesia on postoperative day 1.
