Consenso argentino de ventilación no invasiva / Argentine consensus of non-invasive ventilation

Non-invasive ventilation (NIV) is nowadays increasingly used. The significant decrease in tracheal intubation related complications makes it particularly attractive in patients with moderately acute respiratory failure (ARF) who still have some degree of respiratory autonomy. It has also been used to support patients with chronic respiratory failure. However, final outcomes are variable according to the conditions which determined its application. This Consensus was performed in order to review the evidence supporting the use of positive pressure NIV. The patho-physiological background of NIV and the equipment required technology are described. Available evidence clearly suggests benefits of NIV in acute exacerbation of chronic obstructive pulmonary disease (COPD) and in cardiogenic pulmonary edema (Recommendation A). When considering ARF in the setting of acute respiratory distress syndrome results are uncertain, unless dealing with immunosupressed patients (Recommendation B). Positive results are also shown in weaning of mechanical ventilation (MV), particularly regarding acute exacerbation of COPD patients (Recommendation A). An improved quality of life in chronic respiratory failure and a longer survival in restrictive disorders has also been shown (Recommendation B) while its benefit in stable COPD patients is still controversial (Recommendation C). NIV should be performed according to pre-established standards. A revision of NIV related complications is performed and the cost-benefit comparison with invasive MV is also considered.(AU)

La ventilación no invasiva (VNI) ha alcanzado notable difusión en los últimos años. El ahorro delas complicaciones causadas por la intubación traqueal la hace especialmente atractiva en pacientesque presentan insuficiencia respiratoria aguda (IRA) no muy grave y que conservan cierta autonomía respiratoria.También se han descripto efectos terapéuticos en pacientes con insuficiencia respiratoria crónica de etiologías diversas. No obstante, los resultados obtenidos son variables según las circunstancias que motivan su aplicación. A fin de revisar la evidencia a favor de su uso se elaboró este Consenso referido particularmente a la VNI a presión positiva. Se describen su fundamento fisiopatológico, esencial para su correcta aplicación, y elequipamiento necesario para implementarla. La evidencia existente en la literatura establece definida utilidad de la VNI en la exacerbación de la EPOC y en el edema agudo de pulmón cardiogénico (Recomendación A).Su beneficio es aún incierto en pacientes con IRA secundaria a síndrome de dificultad respiratoria aguda, salvoen el subgrupo de pacientes inmunosuprimidos (Recomendación B). Los resultados son también favorablesen la desvinculación de la asistencia respiratoria mecánica (ARM), especialmente en pacientes ventilados por exacerbación de EPOC (Recomendación A). En la insuficiencia respiratoria crónica se ha hallado mejoría en la calidad de vida y mayor sobrevida en pacientes con enfermedades restrictivas (Recomendación B), mientrasque existe aún controversia sobre su utilidad en pacientes con EPOC estable (Recomendación C). La VNI debeser aplicada con estándares de cuidados que son establecidos. Se revisan las eventuales complicaciones derivadasde su uso y el beneficio costo-efectividad ahorrando recursos de mayor complejidad y disminuyendolos riesgos que implica la ARM invasiva.(AU)

Consenso argentino de ventilación no invasiva / Argentine consensus of non-invasive ventilation

Non-invasive ventilation (NIV) is nowadays increasingly used. The significant decrease in tracheal intubation related complications makes it particularly attractive in patients with moderately acute respiratory failure (ARF) who still have some degree of respiratory autonomy. It has also been used to support patients with chronic respiratory failure. However, final outcomes are variable according to the conditions which determined its application. This Consensus was performed in order to review the evidence supporting the use of positive pressure NIV. The patho-physiological background of NIV and the equipment required technology are described. Available evidence clearly suggests benefits of NIV in acute exacerbation of chronic obstructive pulmonary disease (COPD) and in cardiogenic pulmonary edema (Recommendation A). When considering ARF in the setting of acute respiratory distress syndrome results are uncertain, unless dealing with immunosupressed patients (Recommendation B). Positive results are also shown in weaning of mechanical ventilation (MV), particularly regarding acute exacerbation of COPD patients (Recommendation A). An improved quality of life in chronic respiratory failure and a longer survival in restrictive disorders has also been shown (Recommendation B) while its benefit in stable COPD patients is still controversial (Recommendation C). NIV should be performed according to pre-established standards. A revision of NIV related complications is performed and the cost-benefit comparison with invasive MV is also considered.

La ventilación no invasiva (VNI) ha alcanzado notable difusión en los últimos años. El ahorro delas complicaciones causadas por la intubación traqueal la hace especialmente atractiva en pacientesque presentan insuficiencia respiratoria aguda (IRA) no muy grave y que conservan cierta autonomía respiratoria.También se han descripto efectos terapéuticos en pacientes con insuficiencia respiratoria crónica de etiologías diversas. No obstante, los resultados obtenidos son variables según las circunstancias que motivan su aplicación. A fin de revisar la evidencia a favor de su uso se elaboró este Consenso referido particularmente a la VNI a presión positiva. Se describen su fundamento fisiopatológico, esencial para su correcta aplicación, y elequipamiento necesario para implementarla. La evidencia existente en la literatura establece definida utilidad de la VNI en la exacerbación de la EPOC y en el edema agudo de pulmón cardiogénico (Recomendación A).Su beneficio es aún incierto en pacientes con IRA secundaria a síndrome de dificultad respiratoria aguda, salvoen el subgrupo de pacientes inmunosuprimidos (Recomendación B). Los resultados son también favorablesen la desvinculación de la asistencia respiratoria mecánica (ARM), especialmente en pacientes ventilados por exacerbación de EPOC (Recomendación A). En la insuficiencia respiratoria crónica se ha hallado mejoría en la calidad de vida y mayor sobrevida en pacientes con enfermedades restrictivas (Recomendación B), mientrasque existe aún controversia sobre su utilidad en pacientes con EPOC estable (Recomendación C). La VNI debeser aplicada con estándares de cuidados que son establecidos. Se revisan las eventuales complicaciones derivadasde su uso y el beneficio costo-efectividad ahorrando recursos de mayor complejidad y disminuyendolos riesgos que implica la ARM invasiva.

Streptococcal pyomyositis: case report and review.

Pyomyositis is most often associated with Staphylococcus aureus infections after trauma. We describe an unusual presentation of pyomyositis of the chest wall secondary to group A betahemolytic streptococcus infection in a 15-month-old child with acute abdominal symptoms. In addition, the patient had no history or evidence of trauma to the affected area. Pyomyositis presenting in this manner secondary to group A beta-hemolytic streptococcus infection in the absence of a primary varicella infection has not been previously reported.

Complications after surgical intervention for necrotizing enterocolitis: a multicenter review.

Necrotizing enterocolitis (NEC) is a serious condition affecting predominantly the premature infant. The purpose of this study is to report a multicenter experience of complications in 252 infants requiring surgical therapy for NEC. Data from eight institutions for the years 1980 through 1990 were collected and analyzed for infants undergoing surgical therapy for NEC. Records were reviewed for gestational age, birth weight, age at operation, indications for operation, degree of intestinal involvement, operation(s) performed, complications, and 30-day mortality rates. A total of 264 infants underwent surgical intervention for NEC during the study period. Complete information was available for 252 patients. The mean gestational age was 31 +/- 5 weeks and the mean birth weight was 1,552 +/- 823 g. The mean age at operation was 18 +/- 35 days. Pneumoperitoneum was the most common indication for operation (42%). The 30-day survival rate was 72%. Eighty-one percent of patients underwent primary laparotomy, whereas peritoneal drainage was performed in 48 (19%) patients. Postoperative complications were identified in 119 (47%) patients. The most common postoperative complications were sepsis (9%), intestinal strictures (9%), and short gut (9%). Wound infections occurred in 6%, and the incidence of intraabdominal abscess formation was only 2.3%. Gestational age < 27 weeks (P < .005) and birth weight < 1,000 g (P < .005) were associated with significantly increased mortality but no increase in postoperative morbidity. The incidence of complications was similar in the very low birth weight (< 1,000 g) infants (51%) compared with infants > or = 1,000 g (46%).(ABSTRACT TRUNCATED AT 250 WORDS)

Hemorrhagic complications and repair of congenital diaphragmatic hernias: does timing of the repair make a difference? Data from the Extracorporeal Life Support Organization.

The authors reviewed the Extracorporeal Life Support Organization (ELSO) data base of all neonates placed on extracorporeal membrane oxygenation for whom CDH was diagnosed between January 1989 and December 1991. For 483 neonates, there were complete data concerning timing of the hernia repair in relation to ECMO. The overall incidence of hemorrhage was 43% (57% among nonsurvivors, 32% among survivors; P < .05). The most common bleeding sites were surgical repair site (24%), head (11.5%), cannulation site (7.5%), and gastrointestinal (5%). Fatal hemorrhage occurred in 4.8% (23 of 483). The most common sites of fatal hemorrhage were head (48%), pulmonary (17%), and abdominal (17%). Bleeding complications were significantly greater for patients repaired on ECMO (58%) versus those repaired before (37%) or after (21%) (P < .05). Surgical-site hemorrhage requiring transfusion occurred in 38% of those repaired on ECMO versus 18% and 6% of those repaired before and after, respectively (P < .05). Gastrointestinal and "other" sites of hemorrhage were significantly more common in those repaired on bypass. The number of patients repaired on ECMO increased from 22% to 48% over the 3 years (P < .05). The incidence of hemorrhagic complications did not differ significantly among the 3 years (P > .05). Repair of the hernia defect while on bypass was associated with significantly greater bleeding complications. These data should be useful in the planning of future prospective trials.

Long-chain predominant lipid emulsions inhibit in vitro macrophage tumor necrosis factor production.

Intravenous lipid emulsions are an important component of parenteral nutrition. Despite their benefits, lipid emulsions have been associated with higher rates of bacteremia in neonates. Therefore we investigated the effect of lipid emulsions on the inflammatory response by examining their effect on in vitro macrophage tumor necrosis factor (TNF) production of two distinct macrophage populations. Through the use of endotoxin-free phosphate buffered saline, peritoneal (PER) and alveolar (ALV) macrophages were isolated from male Sprague-Dawley rats (weighing 125 to 150 g) with endotoxin-free phosphate buffered saline. Cell counts were adjusted to 2 x 10(6) cells/mL in RPMI with 2% fetal calf serum. Three hundred microliters of the cells were incubated in a 24-well culture dish with media or media with intralipid (100 micrograms/dL) for 16 hours. After washing each well three times, the cells were stimulated for 2 or 16 hours with Escherichia coli lipopolysaccharide (150 microL of 1 microgram/mL). The supernatants were assayed for TNF using the WEHI 164:13 bioassay and TNF levels were expressed as picograms per milliliter. Student's unpaired t test was used for data analysis. Lipid-exposed PER and ALV macrophages in vitro TNF levels were significantly lower-after 2 hours (12,591 pg/mL +/- 3837 vs 20,591 pg/mL +/- 6344 for PER, 3894 pg/mL +/- 1258 vs 13,177 pg/mL +/- 3266 for ALV) and 16 hours (6427 pg/mL +/- 3050 vs 12,353 pg/mL +/- 4877 for PER; 131,6000 pg/mL +/- 7317 vs 354,680 pg/mL +/- 31,605 for ALV) of endotoxin stimulation. TNF production seems to be impaired in macrophages exposed to a .1% lipid emulsion for 16 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric pelvic fractures combined with an additional skeletal injury is an indicator of significant injury.

Traumatic fractures of the adult pelvic area have high rates of associated injuries and hemorrhagic complications resulting in significant morbidity and mortality. We studied whether or not the plain roentgenographic identification of other fractures is a reliable marker of increased morbidity and mortality in children with pelvic fractures. The records of 79 children admitted with the diagnosis of pelvic fracture from January 1986 through December 1990 were reviewed. Associated injuries were categorized as head, chest, abdomen or skeletal. The pelvic fractures were grouped using the classification system of Torode. Mechanism of injury, age, weight, vitals on admission, operative procedures performed, amount of blood transfused during the first 24 hours, number of days hospitalized, modified injury severity score (MISS) and revised trauma score (RTS) were recorded for each patient. Using any other bony fracture as an easily identifiable additional risk factor, we recorded the associated injuries in those with pelvic fracture and any additional fracture (PF+AF, n = 39) and pelvic fracture alone (PF, n = 40). The PF+AF group demonstrated a significantly higher incidence of head and abdominal injuries and a significantly higher number of required transfusion in the first 24 hours (Fisher's exact test, p < 0.05). Mortality, thoracic injuries and patients requiring laparotomy or an additional nonorthopedic procedure occurred approximately twice as often in the PF+AF group compared with the PF group. However, the numbers were too small to be statistically significant (Fisher's exact, p > 0.05). The PF+AF group also had a significantly higher MISS and average number of days hospitalized (Student's t test, p < 005). The RTS was significantly lower (p < 0.05). In children with pelvic fractures, we found that any additional bony fracture is a significant marker for head and abdominal injury. This constellation identifies patients who may benefit from early transfer to a regional pediatric trauma center.

Prosthetic diaphragm reconstruction in the growing animal.

Widespread use of extracorporeal membrane oxygenation (ECMO) has allowed an increasing number of infants with total agenesis of the diaphragm to survive. Polytetrafluoroethylene (PTFE) is the most widely used material for reconstruction. However, recurrent hernia is a growing problem; PTFE also does not grow with the patient. This study evaluated different materials for diaphragmatic reconstruction in growing animals. Sprague-Dawley rats with a mean weight of 93 g were anesthetized and underwent laparotomy. The control group had an incision into the diaphragm with primary repair. The other three groups underwent complete removal of the left hemidiaphragm and were randomly assigned to one of three reconstruction methods: oxidized cellulose, polyglactin mesh, or a 1-mm PTFE patch. All patch materials were sewn around the ribs circumferentially and into the membranous portion of the central diaphragm medially with 4-0 silk. Thirty-seven animals survived operation, were followed with weekly chest radiographs, and were killed when they reached 400 g. The radiographs were reviewed in a blinded fashion by two observers as were the necropsies, and rib deformity was graded on a scale of 0 to 3. Histological examination of several animals from each group was performed. There was significantly greater rib deformity (2.0 v 0.2, P < .01) in the PTFE group versus controls with 5 of 10 animals also having a smaller thorax. The PTFE pulled away from the chest wall in the animals leaving a fibrous remnant anteriorly. The polyglactin group had significantly more animals with eventration (P < .03, 7/10) compared with all others.(ABSTRACT TRUNCATED AT 250 WORDS)