4 research outputs found
a randomized controlled study
Background Uncertainty persists regarding the optimal ventilatory strategy in
trauma patients developing acute respiratory distress syndrome (ARDS). This
work aims to assess the effects of two mechanical ventilation strategies with
high positive end-expiratory pressure (PEEP) in experimental ARDS following
blunt chest trauma. Methods Twenty-six juvenile pigs were anesthetized,
tracheotomized and mechanically ventilated. A contusion was applied to the
right chest using a bolt-shot device. Ninety minutes after contusion, animals
were randomized to two different ventilation modes, applied for 24 h: Twelve
pigs received conventional pressure-controlled ventilation with moderately low
tidal volumes (VT, 8 ml/kg) and empirically chosen high external PEEP
(16cmH2O) and are referred to as the HP-CMV-group. The other group (n = 14)
underwent high-frequency inverse-ratio pressure-controlled ventilation (HFPPV)
involving respiratory rate of 65breaths · min−1, inspiratory-to-expiratory-
ratio 2:1, development of intrinsic PEEP and recruitment maneuvers, compatible
with the rationale of the Open Lung Concept. Hemodynamics, gas exchange and
respiratory mechanics were monitored during 24 h. Computed tomography and
histology were analyzed in subgroups. Results Comparing changes which occurred
from randomization (90 min after chest trauma) over the 24-h treatment period,
groups differed statistically significantly (all P values for group effect
<0.001, General Linear Model analysis) for the following parameters (values
are mean ± SD for randomization vs. 24-h): PaO2 (100 % O2) (HFPPV 186 ± 82 vs.
450 ± 59 mmHg; HP-CMV 249 ± 73 vs. 243 ± 81 mmHg), venous admixture (HFPPV 34
± 9.8 vs. 11.2 ± 3.7 %; HP-CMV 33.9 ± 10.5 vs. 21.8 ± 7.2 %), PaCO2 (HFPPV
46.9 ± 6.8 vs. 33.1 ± 2.4 mmHg; HP-CMV 46.3 ± 11.9 vs. 59.7 ± 18.3 mmHg) and
normally aerated lung mass (HFPPV 42.8 ± 11.8 vs. 74.6 ± 10.0 %; HP-CMV 40.7 ±
8.6 vs. 53.4 ± 11.6 %). Improvements occurring after recruitment in the HFPPV-
group persisted throughout the study. Peak airway pressure and VT did not
differ significantly. HFPPV animals had lower atelectasis and inflammation
scores in gravity-dependent lung areas. Conclusions In this model of ARDS
following unilateral blunt chest trauma, HFPPV ventilation improved
respiratory function and fulfilled relevant ventilation endpoints for trauma
patients, i.e. restoration of oxygenation and lung aeration while avoiding
hypercapnia and respiratory acidosis
Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department
Introduction
The survival of patients admitted to an emergency department is determined by the severity of acute illness and the quality of care provided. The high number and the wide spectrum of severity of illness of admitted patients make an immediate assessment of all patients unrealistic. The aim of this study is to evaluate a scoring system based on readily available physiological parameters immediately after admission to an emergency department (ED) for the purpose of identification of at-risk patients.
Methods
This prospective observational cohort study includes 4,388 consecutive adult patients admitted via the ED of a 960-bed tertiary referral hospital over a period of six months. Occurrence of each of seven potential vital sign abnormalities (threat to airway, abnormal respiratory rate, oxygen saturation, systolic blood pressure, heart rate, low Glasgow Coma Scale and seizures) was collected and added up to generate the vital sign score (VSS). VSSinitial was defined as the VSS in the first 15 minutes after admission, VSSmax as the maximum VSS throughout the stay in ED. Occurrence of single vital sign abnormalities in the first 15 minutes and VSSinitial and VSSmax were evaluated as potential predictors of hospital mortality.
Results
Logistic regression analysis identified all evaluated single vital sign abnormalities except seizures and abnormal respiratory rate to be independent predictors of hospital mortality. Increasing VSSinitial and VSSmax were significantly correlated to hospital mortality (odds ratio (OR) 2.80, 95% confidence interval (CI) 2.50 to 3.14, P < 0.0001 for VSSinitial; OR 2.36, 95% CI 2.15 to 2.60, P < 0.0001 for VSSmax). The predictive power of VSS was highest if collected in the first 15 minutes after ED admission (log rank Chi-square 468.1, P < 0.0001 for VSSinitial;,log rank Chi square 361.5, P < 0.0001 for VSSmax).
Conclusions
Vital sign abnormalities and VSS collected in the first minutes after ED admission can identify patients at risk of an unfavourable outcome