Principles, protocols and patients: the practical management of a limit in ICU.

The definition and management of a limit is a common but sometimes extremely complex problem in the Intensive Care Unit (ICU). Guidelines and consensus documents have been published in order to help clinicians. Yet, many controversial issues are brought into question. Legal rules are sometimes vague and derive more from the interpretation of various and unrelated principles (which vary from country to country) than from a clear ad hoc law. In this sense, the practical management of a limit in ICU is usually run by a dual normativity: an external one, which derives from the cultural, moral and legal values of the society, and an internal one, which depends on the particular clinical and human situation, namely the values of everybody involved in (the patient, his/her relatives, the health staff) and the relationships among these people. The considerable freedom left for the decision by an open communication is a great and favourable potential which must be used in the interest of the patient's and of his/her family.

Comparative evaluation of the haemodynamic effects of continuous negative external pressure (CNEP) and positive end-expiratory pressure (PEEP) in mechanically ventilated trauma patients.

OBJECTIVE: To compare the haemodynamic effects of identical values of continuous negative external pressure (CNEP) and positive end-expiratory pressure (PEEP) in a group of mechanically ventilated patients. SETTING: General ICU, Vicenza Hospital, Italy. PATIENTS: 15 consecutive patients, admitted after road accident trauma. METHODS: We compared the haemodynamic effects of ZEEP, 10 cmH2O of PEEP, and 10 cmH2O CNEP, applied in random order, in 15 head trauma patients under going controlled mechanical ventilation; 9 had associated thoracic trauma, while 6 did not have lung involvement. CNEP was obtained with a "poncho". RESULTS: We observed a significant increase in CI during CNEP, compared with both ZEEP and PEEP 10 cmH2O. Accordingly the oxygen delivery index significantly increased during CNEP, compared with PEEP 10 cmH2O. Conversely, Qs/Qt decreased with CNEP, if compared with PEEP, both in patients with and without lung damage. CONCLUSION: CNEP can significantly increase CI in mechanically ventilated patients in patients with and without associated lung damage.