Effect of external PEEP in patients under controlled mechanical ventilation with an auto-PEEP of 5 cmH2O or higher.

In some patients with auto-positive end-expiratory pressure (auto-PEEP), application of PEEP lower than auto-PEEP maintains a constant total PEEP, therefore reducing the inspiratory threshold load without detrimental cardiovascular or respiratory effects. We refer to these patients as complete PEEP-absorbers. Conversely, adverse effects of PEEP application could occur in patients with auto-PEEP when the total PEEP rises as a consequence. From a pathophysiological perspective, all subjects with flow limitation are expected to be complete PEEP-absorbers, whereas PEEP should increase total PEEP in all other patients. This study aimed to empirically assess the extent to which flow limitation alone explains a complete PEEP-absorber behavior (i.e., absence of further hyperinflation with PEEP), and to identify other factors associated with it.One hundred patients with auto-PEEP of at least 5 cmH2O at zero end-expiratory pressure (ZEEP) during controlled mechanical ventilation were enrolled. Total PEEP (i.e., end-expiratory plateau pressure) was measured both at ZEEP and after applied PEEP equal to 80 % of auto-PEEP measured at ZEEP. All measurements were repeated three times, and the average value was used for analysis.Forty-seven percent of the patients suffered from chronic pulmonary disease and 52 % from acute pulmonary disease; 61 % showed flow limitation at ZEEP, assessed by manual compression of the abdomen. The mean total PEEP was 7 ± 2 cmH2O at ZEEP and 9 ± 2 cmH2O after the application of PEEP (p < 0.001). Thirty-three percent of the patients were complete PEEP-absorbers. Multiple logistic regression was used to predict the behavior of complete PEEP-absorber. The best model included a respiratory rate lower than 20 breaths/min and the presence of flow limitation. The predictive ability of the model was excellent, with an overoptimism-corrected area under the receiver operating characteristics curve of 0.89 (95 % CI 0.80-0.97).Expiratory flow limitation was associated with both high and complete PEEP-absorber behavior, but setting a relatively high respiratory rate on the ventilator can prevent from observing complete PEEP-absorption. Therefore, the effect of PEEP application in patients with auto-PEEP can be accurately predicted at the bedside by measuring the respiratory rate and observing the flow-volume loop during manual compression of the abdomen

Driving pressure during general anesthesia for open abdominal surgery (DESIGNATION) : study protocol of a randomized clinical trial

Background Intraoperative driving pressure (Delta P) is associated with development of postoperative pulmonary complications (PPC). When tidal volume (V-T) is kept constant, Delta P may change according to positive end-expiratory pressure (PEEP)-induced changes in lung aeration. Delta P may decrease if PEEP leads to a recruitment of collapsed lung tissue but will increase if PEEP mainly causes pulmonary overdistension. This study tests the hypothesis that individualized high PEEP, when compared to fixed low PEEP, protects against PPC in patients undergoing open abdominal surgery. Methods The "Driving prESsure durIng GeNeral AnesThesIa for Open abdomiNal surgery trial" (DESIGNATION) is an international, multicenter, two-group, double-blind randomized clinical superiority trial. A total of 1468 patients will be randomly assigned to one of the two intraoperative ventilation strategies. Investigators screen patients aged >= 18 years and with a body mass index <= 40 kg/m(2), scheduled for open abdominal surgery and at risk for PPC. Patients either receive an intraoperative ventilation strategy with individualized high PEEP with recruitment maneuvers (RM) ("individualized high PEEP") or one in which PEEP of 5 cm H2O without RM is used ("low PEEP"). In the "individualized high PEEP" group, PEEP is set at the level at which Delta P is lowest. In both groups of the trial, V-T is kept at 8 mL/kg predicted body weight. The primary endpoint is the occurrence of PPC, recorded as a collapsed composite of adverse pulmonary events. Discussion DESIGNATION will be the first randomized clinical trial that is adequately powered to compare the effects of individualized high PEEP with RM versus fixed low PEEP without RM on the occurrence of PPC after open abdominal surgery. The results of DESIGNATION will support anesthesiologists in their decisions regarding PEEP settings during open abdominal surgery

Optimization of Clifford Circuits

We study optimal synthesis of Clifford circuits, and apply the results to peep-hole optimization of quantum circuits. We report optimal circuits for all Clifford operations with up to four inputs. We perform peep-hole optimization of Clifford circuits with up to 40 inputs found in the literature, and demonstrate the reduction in the number of gates by about 50%. We extend our methods to the optimal synthesis of linear reversible circuits, partially specified Clifford functions, and optimal Clifford circuits with five inputs up to input/output permutation. The results find their application in randomized benchmarking protocols, quantum error correction, and quantum circuit optimization.Comment: 7 pages, 5 figure

Peep Show

An Army veteran reaches out to protect the younger generation when a teen wanders into an adult video shop. Articles, stories, and other compositions in this archive were written by participants in the Mighty Pen Project. The program, developed by author David L. Robbins, and in partnership with Virginia Commonwealth University and the Virginia War Memorial in Richmond, Virginia, offers veterans and their family members a customized twelve-week writing class, free of charge. The program encourages, supports, and assists participants in sharing their stories and experiences of military experience so both writer and audience may benefit

Reliability of Single-Use PEEP-Valves Attached to Self-Inflating Bags during Manual Ventilation of Neonates – An In Vitro Study

Introduction International resuscitation guidelines suggest to use positive end-expiratory pressure (PEEP) during manual ventilation of neonates. Aim of our study was to test the reliability of self-inflating bags (SIB) with single-use PEEP valves regarding PEEP delivery and the effect of different peak inflation pressures (PIP) and ventilation rates (VR) on the delivered PEEP. Methods Ten new single-use PEEP valves from 5 manufacturers were tested by ventilating an intubated 1kg neonatal manikin containing a lung model with a SIB that was actuated by an electromechanical plunger device. Standard settings: PIP 20cmH2O, VR 60/min, flow 8L/min. PEEP settings of 5 and 10cmH2O were studied. A second test was conducted with settings of PIP 40cmH2O and VR 40/min. The delivered PEEP was measured by a respiratory function monitor (CO2SMO+). Results Valves from one manufacturer delivered no relevant PEEP and were excluded. The remaining valves showed a continuous decay of the delivered pressure during expiration. The median (25th and 75th percentile) delivered PEEP with standard settings was 3.4(2.7–3.8)cmH2O when set to 5cmH2O and 6.1(4.9–7.1)cmH2O when set to 10cmH2O. Increasing the PIP from 20 to 40 cmH2O led to a median (25th and 75th percentile) decrease in PEEP to 2.3(1.8–2.7)cmH2O and 4.3(3.2–4.8)cmH2O; changing VR from 60 to 40/min led to a PEEP decrease to 2.8(2.1–3.3)cmH2O and 5.0(3.5–6.2)cmH2O for both PEEP settings. Conclusion Single-use PEEP valves do not reliably deliver the set PEEP. PIP and VR have an effect on the delivered PEEP. Operators should be aware of these limitations when manually ventilating neonates

Detection of 'best' positive end-expiratory pressure derived from electrical impedance tomography parameters during a decremental positive end-expiratory pressure trial

Introduction: This study compares different parameters derived from electrical impedance tomography (EIT) data to define 'best' positive end-expiratory pressure (PEEP) during a decremental PEEP trial in mechanically-ventilated patients. 'Best' PEEP is regarded as minimal lung collapse and overdistention in order to prevent ventilator-induced lung injury.Methods: A decremental PEEP trial (from 15 to 0 cm H2O PEEP in 4 steps) was performed in 12 post-cardiac surgery patients on the ICU. At each PEEP step, EIT measurements were performed and from this data the following were calculated: tidal impedance variation (TIV), regional compliance, ventilation surface area (VSA), center of ventilation (COV), regional ventilation delay (RVD index), global inhomogeneity (GI index), and intratidal gas distribution. From the latter parameter we developed the ITV index as a new homogeneity parameter. The EIT parameters were compared with dynamic compliance and the PaO2/FiO2 ratio.Results: Dynamic compliance and the PaO2/FiO2 ratio had the highest value at 10 and 15 cm H2O PEEP, respectively. TIV, regional compliance and VSA had a maximum value at 5 cm H2O PEEP for the non-dependent lung region and a maximal value at 15 cm H2O PEEP for the dependent lung regio

Ravimpreparaatide väljatöötamise tulevikusuunad

Kui veel eelmise sajandi kaheksakümnendatel aastatel räägiti ja kirjutati “revolutsioonist” ravimpreparaatide arengus 21. sajandil ning seostati seda eelkõige bioloogiateadustes toimuvate murranguliste avastustega, siis praegu ollakse kaugeleulatuvate prognooside tegemisel ettevaatlikum

Conodont dating of some Telychian (Silurian) sections in Estonia

Several Telychian–Sheinwoodian strata exposed in Estonia are precisely dated using conodont biostratigraphy. The beds in the Valgu-1 section correspond to the uppermost Distomodus staurognathoides and Pterospathodus eopennatus ssp. n. 1 zones. In the Valgu-2 and Valgu-3 sections only the P. eopennatus ssp. n. 1 Zone is exposed. The strata in the Velise-Kõrgekalda section correspond to the Lower subzone of the P. amorphognathoides angulatus Zone. Marlstones in the Jädivere section are assigned to the P. a. lennarti Zone. In the Avaste section part of the P. a. lithuanicus Zone is exposed. On the Saastna Peninsula two stratigraphical intervals, the lower corresponding to the Upper subzone of the P. a. amorphognathoides Zone and the upper to the Upper Kockelella ranuliformis Zone, crop out along the shoreline. In Saastna the exposed strata are separated by a covered interval corresponding to five conodont zones, from the Lower Pseudooneotodus bicornis Zone to the Lower K. ranuliformis Zone

Fiiberureterorenoskoopia neerukivitõve ravis

Neerukivitõve ravis on kogu arenenud maailmas juhtival kohal endoskoopiline ja väheinvasiivne kirurgia. Peamisteks tänapäevasteks ravimeetoditeks on kehaväline kivipurustus, perkutaanne nefroskoopia ja ureterorenoskoopia, mis Eesti Uroloogide Seltsi andmetel 2007. a moodustasid kivitõve ravis Eestis vastavalt 28, 10 ja 60% tehtud operatsioonidest. Põhja-Eesti Regionaalhaigla (PERH) uroloogiaosakonnas alustati fiiberureterorenoskoopiaga 2007. aastal. Protseduur on väheinvasiivne, tüsistusi esineb nii operatsiooni ajal kui pärast seda vähe. Ureterorenoskoopia ravitulemus neerukivitõve ravis on võrreldav kehavälise kivipurustusega, mis on tänu tehnoloogia arengule viimastel aastatel tõusnud sellele oluliseks alternatiiviks. Meie esmasele kogemusel tuginedes on fiiberureterorenoskoopia näidustatud just alla 1 cm neerukivide, hulgikivide, adipoossete patsientide, antikoagulantide tarvitajate ja alumise neerukarika kivide ravis. Eesti Arst 2009; 88(5):340−34