ARDS and adrenal insufficiency associated with the antiphospholipid antibody syndrome.

The antiphospholipid antibody syndrome (APS) is typically characterized by recurrent arterial and/or venous thromboses, miscarriages, and thrombocytopenia. There have been five reported cases of ARDS associated with primary APS. Adrenal insufficiency has also been reported as a rare complication of APS. We report a case of both ARDS and adrenal insufficiency associated with primary APS. Chest radiographs and pulmonary angiography studies revealed findings consistent with ARDS. CT scans confirmed the presence of bilateral adrenal hemorrhagic infarction. Patients with APS are at an increased risk of widespread vascular thrombosis due to the presence of circulating antiphospholipid antibodies. This case emphasizes the importance of recognizing APS and its potential for multiple organ system involvement.

Significance of elevated pancreatic enzymes in intracranial bleeding.

Hyperamylasemia of pancreatic origin has been noted in patients with severe head injury without abdominal trauma or evidence of pancreatitis. Thirty-eight patients with intracranial bleeding of various types were evaluated for elevated pancreatic amylase and lipase enzymes without associated pancreatitis. Twenty-five patients had elevated serum lipase; 17 of 25 also had elevated amylase without pancreatitis. Most lipase elevations occurred earlier than those of amylase. Six clinical variables--mannitol, ceftriaxone, nimodipine, steroids, Glasgow Coma Score, and total parenteral and enteral hyperalimentation--were evaluated to determine relationship to the enzyme elevations. A significant relationship exists between patients not treated with steroids and elevated lipase and amylase enzyme activities. Multivariate analysis revealed a significant interaction between lipase elevation and decreasing Glasgow Coma Score, indicative of increasing severity of intracranial bleeding. Proposed causes of enzyme elevations in intracranial bleeding include vagal stimulation, altered modulation of the central control of pancreatic enzyme release, and release of cholecystokinin from the brain. Physician awareness of the association of intracranial bleeding with the elevation of amylase and lipase without pancreatitis can save the patient needless cost and manipulation.

Unplanned extubations.

STUDY OBJECTIVE: A prospective study of all unplanned adult extubations was conducted for 4 months period in four intensive care units (ICUs) of a community hospital. Our objective was to document the incidence of unplanned extubations, discern possible variables predictive of occurrence and outcome, and formulate preventive measures and guidelines for reintubation. DESIGN: Prospective case series. SETTING: Hospital with 525 beds and four ICUs: medical-surgical-trauma, neurology-neurosurgery, cardiovascular, and coronary care. PATIENTS: All adult patients intubated in four ICUs for a 4-month period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of 460 adults intubated in the 4-month period, 13 (3 percent) unplanned extubations occurred. Six patients were reintubated because of apnea, tachypnea, hypoxia, or other factors. Seven were not reintubated. Variables examined included the ventilator settings before to self-extubation, duration of intubation, arterial blood gases after self-extubation, Glasgow Coma Scale and Acute Physiology and Chronic Health Enquiry (APACHE) scores, time and location (ICU), nasal or oral method of intubation, and the mechanism of self-extubation. CONCLUSIONS: Our data suggested that self-extubation is relatively rare in our institution and that about half of self-extubated patients were reintubated. Staff vigilance, a proper weaning period, and the nasal method of intubation were some of the factors to which we attributed this low occurrence rate. However, a larger patient study population is required to show conclusively effective preventive measures and establish guidelines for reintubation.

Pulse oximetry monitoring can change routine oxygen supplementation practices in the postanesthesia care unit.

Routine use of supplemental oxygen (O2) in the postanesthesia care unit (PACU) traditionally has been used to minimize the incidence of hypoxemia. However, with the advent of continuous noninvasive monitoring by pulse oximetry, is routine administration of O2 necessary? We hypothesized that administering O2 as needed, based on pulse oximetry data, would effect considerable cost savings without compromising patient care. Five hundred adult (> or = 18 yr) patients breathing room air when arriving in the PACU were enrolled in the study. During PACU care, when O2 saturation (SpO2) was continuously more than 94%, no supplemental O2 was given. When SpO2 was less than 94%, supplemental O2 was given at an inspired O2 concentration (FIO2) that would increase it to above 94%. Also, when preoperative SpO2 was less than 94% and postoperative SpO2 was more than the preoperative SpO2, no supplemental O2 was given. Supplemental O2 was unnecessary in 63% of patients for the duration of their PACU stay. Cost savings to the 307 patients in one study not receiving O2 was $31,928 if it had been billed separately from the PACU global charge. The annualized figure for patients in our hospital (approximately 10,000 cases) would be an additional $623,272. Inasmuch as pulse oximetry monitoring is now standard in the PACU, perhaps it is time to apply the objective data it supplies, thereby creating cost savings while maintaining patient care standards.

The treatment of osteomyelitis underlying pressure ulcers.

Osteomyelitis is recognized as an often intractable hindrance to healing in the deep pressure ulcer. The mainstays of treatment of this disease have traditionally been surgical debridement followed by muscle flap revascularization, supplemented by antibiotic coverage. Hyperbaric oxygenation has also been shown to be effective in healing refractory osteomyelitis when used as an adjunct to surgical and medical therapy. This review defines the disease, and presents a current literature review and discussion of its treatment, including adequacy of debridement, options for wound closure, appropriate antimicrobial strategy, and the role of hyperbaric oxygenation. A short review of investigational modalities is also included.

Right ventricular hypertrophy detected by echocardiography in patients with newly diagnosed obstructive sleep apnea.

We used polysomnography, echocardiography and ventilatory measurements to study 50 patients suspected of having OSA to determine a link to RVH. Twenty-eight patients (56 percent) had OSA and 20 (71 percent) of those had isolated RVH. We evaluated patients with RVH and divided them into two groups, those with apnea and those without apnea. The patients with sleep apnea were younger, weighed more, had greater BSA and had lower average oxygen saturations during the sleep study period. We divided the group with apnea into those with RVH and those without it. Those patients with RVH had a higher AI, longer average apnea time, a greater duration of longest apnea and a lower average oxygen saturation for the period of the sleep study. In addition, those with RVH had a lower average oxygen saturation during each apneic episode with a p value equaling 0.09.

Effect of positive end-expiratory pressure on intra-abdominal pressure.

Massive elevation of intra-abdominal pressure (IAP) causes renal, cardiovascular, and respiratory dysfunction. Positive end-expiratory pressure (PEEP) markedly increases the detrimental effect of IAP on the cardiovascular system. The purpose of this study was to determine the effect of PEEP on IAP. In 15 patients requiring mechanical ventilation, IAP was measured, after 15-minute equilibration intervals, at PEEP levels of 0, 5, 10, and 15 cm H2O. Parametric analysis with multiple paired t tests and nonparametric analysis with Spearman's rho and Kendall's tau tests were used to determine correlation between PEEP and IAP. All patients were male. The mean age was 39 years (range, 18-77). Ten patients had just had laparotomy. No correlation was found between PEEP and IAP. We conclude that PEEP of 15 cm H2O or less has no effect on IAP, and we discuss the clinical implications.

Bilateral diaphragmatic paralysis.

Ventilatory failure developed insidiously in a patient due to bilateral diaphragmatic paralysis from bilateral phrenic neuropathy. The ventilatory failure progressed to respiratory arrest. We assessed the patient's diaphragmatic function by fluoroscopy, transdiaphragmatic pressure measurements during maximal inspiration, measurement of abdominal paradoxic motion, and electrical conduction measurements of the phrenic nerves. He improved and was discharged. A rocking bed was recommended for sleep after appropriate measurements of various respiratory support apparatuses. A history of supine breathlessness and a clinical observation of paradoxic abdominal wall motion during breathing in the supine position should suggest this possible cause.

Pulmonary infection with Petriellidium boydii.

A 52-year-old woman with pulmonary involvement with Petriellidium boydii in a bronchiectatic lung segment is described. Pulmonary involvement with this organism has been most frequently described in patients with underlying systemic diseases or compromised immune systems. This patient apparently had neither problem and was normal in all other aspects. Surgical resection was done to avoid local pulmonary parenchymal invasion or dissemination of this fungus. The patient is now in good health two years after operation.

Permanent contraception.

PIP: Male and female sterilization has become the 2nd leading form of contraception in recent years. The procedures are discussed with focus on the emotional sequelae of either operation. Both members of the marital unit should be involved in the decision for permanent contraception. The sterilizing procedure itself should be performed on the most motivated of the pair. Motivation, psychological stability, religious accord, and marital stability are important prerequisites for a successful procedure.^ieng