Prone Positioning for ARDS. still misunderstood and misused

Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by a non-cardiogenic pulmonary edema with bilateral chest X-ray opacities and hypoxemia refractory to oxygen therapy and low level of positive end-expiratory pressure (1). Recently, a large observational study reported an ARDS prevalence of 10.4% of all ICU admissions and of 23.4% of all subjects receiving mechanical ventilation (2). Despite these alarming numbers, according to the most recent literature, ARDS is still under-recognized, undertreated, and associated with a mortality rate that in the most severe forms is close to 50% (2)

Tap block in chronic pain treatment: a case of entrapment syndrome of iliohypogastric and ilioininguinal nerves

The patient is a 42 years old woman with entrapment syndrome of the “nerves of passage” – ilioinguinal (IING) and Iliohypogastric (IHPO) – after abdominal surgery. The patient was suffering for IV stage infiltrating endometriosis and went through 13 abdominal surgical interventions (laparoscopic and open). Consequently, she developed chronic neuropathic pain in the IING and IHPO areas, unresponsive to drug therapy. Ultrasound images showed a subverted anatomy with fibrosis of the involved nerves. After three TAP (transversus abdominis plane) block sessions the ultrasound sight resulted improved: a significant amount of preexistent adhesions had lysed and pain was considerably reduced. Temporarily, pain totally disappeared and gradually resume with different features in terms of intensity and continuity. This case highlights the possibility to treat this kind of painful iatrogenic syndromes of injurious and adhesive nature with this technique, with variations in imaging aspects as well as in clinical symptoms. In this particular case we did not get a total resolution of pain, maybe due to the long history of the symptoms and their chronicity. The study of a number of pain cases of more recent onset could be extremely useful in the evaluation of this technique, as suggested by this case history

Adaptive support ventilation versus synchronized intermittent mandatory ventilation with pressure support in weaning patients after orthotopic liver transplantation

BACKGROUND: The extubation phase is an extremely critical moment in patients who have undergone orthotopic liver transplantation, who do not always have the advantage of long-lasting positive-pressure ventilation and positive expiratory end pressure; these factors can lead to splanchnic venous congestion, and this is why a rapid extubation can represent a great benefit for the graft. METHODS: The aim of this study was to compare the adaptive support ventilation (ASV) mode with the standard mode of weaning in our intensive care unit, synchronized intermittent mandatory ventilation with pressure support (P-SIMV), in patients who received orthotopic liver transplantation. ASV is a positive-pressure mode, in which pressure level and respiratory rate are automatically adjusted according to measured lung dynamics at each breath. Eligible patients were assigned to either ASV or P-SIMV group. The weaning protocol was based on the individual respiratory activity and structured in 4 different phases. RESULTS: The average length of intubation was significantly shorter in the ASV group than in the P-SIMV group (90±13 vs 153±22 minutes, P=.05). The total modifications to the ventilator settings were significantly larger in the P-SIMV group (1.5±1 vs 6±2; P=.003). CONCLUSIONS: Our results suggest that although both procedures are safe and easy to apply, ASV is superior in terms of weaning times, and it simplifies respiratory management. The better patient-machine interaction in ASV has been highlighted by other authors for different clusters of patients