Extracorporeal membrane oxygenation with danaparoid sodium after massive pulmonary embolism.

During extracorporeal membrane oxygenation, anticoagulation therapy is usually achieved with unfractionated heparin. We report on an extracorporeal membrane oxygenation with danaparoid sodium for a patient with severe respiratory failure due to massive pulmonary embolism and suspected type 2 heparin-induced thrombocytopenia. Danaparoid, a low molecular weight heparinoid, is an alternative to heparin for patients who develop type 2 heparin-induced thrombocytopenia. Danaparoid was given at 400 IU/h with an objective of antifactor Xa activity of 0.6-0.8 U/mL, which was monitored twice a day. No excessive bleeding or clotting of the circuit was noted. The patient was weaned from extracorporeal membrane oxygenation after 9 days of treatment.

Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study.

BACKGROUND: The authors conducted a patient-based survey of practices to fully describe the assessment and the management of pain and sedation of a large cohort of mechanically ventilated patients during their first week of intensive care unit (ICU) stay. METHODS: A total of 1,381 adult patients were included in a prospective, observational study in 44 ICUs in France. Pain and sedation assessment, analgesic and sedative use, and analgesic management during procedural pain were collected on days 2, 4, and 6 of the ICU stay. RESULTS: The observed rates of assessment on day 2 for sedation (43%) and analgesia (42%) were significantly smaller than that of use of sedatives (72%) and opioids (90%), also noted on days 4 and 6. The use of protocols/guidelines for sedation/analgesia in the ICU reduced the proportion of patients who were treated, although not evaluated. A large proportion of assessed patients were in a deep state of sedation (40-50%). Minor changes in the dosages of the main prescribed agents for sedation (midazolam, propofol) and analgesia (sufentanil, fentanyl, morphine, remifentanil) were found across 6 days of the patient's ICU stay. Procedural pain was specifically managed for less than 25% of patients; during those procedures, the proportion of patients with pain significantly increased from the baseline pain evaluation. CONCLUSIONS: Excessively deep states of sedation and a lack of analgesia during painful procedures must be prevented. To facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it seems crucial to promote educational programs and elaboration of protocols/guidelines in the ICU.

Comparaçäo entre a medida do débito cardíaco contínuo com a termodiluiçäo clássica em bolus após cirurgia cardíaca / Comparison of continuous versus bolus cardiac output measurement following valvular surgery

Justificativa e objetivos - a avaliaçäo do débito cardíaco na prática clínica é realizada de forma corrente pelo método de termodiluiçäo. Esta informaçäo é importante, principalmente em pacientes hemodinamicamente instáveis ou em pacientes com doenças cardíacas que väo se submeter a cateterismo cardíaco ou a cirurgia cardíaca. Um novo cateter, com um filamento térmico, permite medir continuamente o débito cardíaco. O objetivo deste estudo foi comparar a medida do débito cardíaco contínuo (DCC) utilizando um cateter na artéria pulmonar, acoplado a um filamento térmico, com o método de medida do débito cardíaco por bolus (DCB) de uma soluçäo fria, no pós-operatório imediato de cirurgia cardíaca para troca valvular. Método - Em vinte e dois pacientes que se submeteram a cirurgia valvular mitral ou aórtica, com circulaçäo extracorpórea hipotérmica, o DCC e DBC, em associaçäo com outros parâmetros hemodinâmicos, foram medidos a cada vinte minutos durante três horas no pós-operatório imediato. Resultados - 198 pares de medidas foram obtidos e comparados. O coeficiente de correlaçä foi de 0,89 (p<0,05). A diferença média do DCB - DCC ñ 0,6 L.min elevado a menos um, e näo foi afetada pela presença de fibrilaçäo atrial. Conclusöes - a comparaçäo destes dois métodos foi satisfatória nestes tipos de pacientes. O DCC aprsenta-se como um método interessante na detecçäo de baixo débito cardíaco imediatamente após cirurgia cardíaca para troca valvular