Approaches and techniques to avoid development or progression of acute respiratory distress syndrome

PURPOSE OF REVIEW: Despite major improvement in ventilation strategies, hospital mortality and morbidity of the acute respiratory distress syndrome (ARDS) remain high. A lot of therapies have been shown to be ineffective for established ARDS. There is a growing interest in strategies aiming at avoiding development and progression of ARDS. RECENT FINDINGS: Recent advances in this field have explored identification of patients at high-risk, nonspecific measures to limit the risks of inflammation, infection and fluid overload, prevention strategies of ventilator-induced lung injury and patient self-inflicted lung injury, and pharmacological treatments. SUMMARY: There is potential for improvement in the management of patients admitted to intensive care unit to reduce ARDS incidence. Apart from nonspecific measures, prevention of ventilator-induced lung injury and patient self-inflicted lung injury are of major importance

Clinical review: bedside assessment of alveolar recruitment

Recruitment is a dynamic physiological process that refers to the reopening of previously gasless lung units. Cumulating evidence has led to a better understanding of the rules that govern both recruitment and derecruitment during mechanical ventilation of patients with acute respiratory distress syndrome. Therefore not only the positive end-expiratory pressure, but also the tidal volume, the inspired oxygen fraction, repeated tracheal suctioning as well as sedation and paralysis may affect recruitment of acute respiratory distress syndrome lungs that are particularly prone to alveolar instability. In the present article, we review the recently reported data concerning the physiological significance of the pressure-volume curve and its use to assess alveolar recruitment. We also describe alternate techniques that have been proposed to assess recruitment at the bedside. Whether recruitment should be optimized remains an ongoing controversy that warrants further clinical investigation

First Report of Lamotrigine-Induced Drug Rash with Eosinophilia and Systemic Symptoms Syndrome with Pancreatitis

OBJECTIVE To report a case of lamotrigine-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome with pancreatitis as the initial visceral involvement.CASE SUMMARY A 75-year-old man was admitted to the local hospital for generalized tonic-clonic seizures. Results of the clinical examination and neurologic investigations were unremarkable. Lamotrigine treatment was initiated and the patient was discharged a few days later. Forty days after lamotrigine initiation, he developed an exanthematous maculopapular rash with fever, peripheral lymphadenopathies, and hypereosinophilia. Lamotrigine hypersensitivity was suspected and the drug was suspended on day 45. On day 47, the patient presented with acute abdominal pain with an elevated lipase level. Acute pancreatitis was confirmed on computed tomography scan. The patient\u27s condition worsened and he was transferred to the intensive care unit with multiorgan failure. The diagnosis of lamotrigine-induced DRESS syndrome was confirmed by a compatible skin histology and concomitant human herpesvirus-6 infection. DISCUSSION This observation has 2 points of interest. First, pancreatic toxicity of lamotrigine has been rarely reported in the literature. Secondly, pancreatitis is uncommon at the early stage of DRESS syndrome. Only 1 other case of DRESS syndrome, secondary to allopurinol, reports pancreatitis along with an Epstein-Barr virus infection. The Naranjo probability scale indicated a probable causality between lamotrigine and DRESS syndrome in this patient. CONCLUSIONS This is the first reported case of lamotrigine-induced DRESS syndrome with pancreatitis as the initial visceral involvement. Clinicians should be aware of this mode of presentation of DRESS syndrome

Successfully treated necrotizing fasciitis using extracorporeal life support combined with hemoadsorption device and continuous renal replacement therapy

INTRODUCTION: Necrotizing fasciitis represents a life-threatening infectious condition that causes spreading necrotisis of superficial fascia and subcutaneous cellular tissues. We describe the case of a patient diagnosed with septic and toxic shocks leading to multiple organ failure successfully treated with a combination of extracorporeal life support, continuous renal replacement therapy, and a hemoadsorption device. METHODS: A 41-year-old patient presented with necrotizing fasciitis and multi-organ failure. Initial extracorporeal life support therapy was implanted, compensating for systolic failure. Due to acute renal failure that persisted in time, continuous renal replacement therapy was added. Despite these treatments and as a last attempt to control the septic condition, a CytoSorb hemoadsorption device was installed in parallel to the extracorporeal life support circuit and two sessions were run. RESULTS: During the days following CytoSorb treatment, hemodynamic stabilization was observed, as well as normalization of lactic acidosis and blood parameters. CONCLUSION: This case describes the successful use of CytoSorb with continuous renal replacement therapy and extracorporeal life support in a combined way to overcome a critical phase of septic shock in a young adult patient. This combination of treatments turned out to be efficient for this patient in the context of necrotizing fasciitis

Understanding hypoxemia on ECCO2R: back to the alveolar gas equation

Extracorporeal CO2 removal (ECCO2R) is a promising technique for ARDS and for severe acute exacerbations of COPD [1]. However, ECCO2R carries its own risk of complications and side effects. Beyond hemorrhagic and thrombotic complications and hemolysis, the occurrence of progressive hypoxemia has been reported in COPD patients treated by ECCO2R, leading to a tracheal intubation rate of 28% in the prospective series from Braune et al. [2]. Obviously, progressive hypoxemia can be explained by pulmonary complications such as evolving infiltrates, even if other factors such as modification of the respiratory quotient have been proposed [2, 3]. Accordingly, we illustrate such a mechanism, intrinsically linked to the ECCO2R technique and not involving any worsening of lung function by itself. A 76-year-old man was admitted because of a very severe hypercapnic acute exacerbation of a chronic respiratory failure due to non-cystic fibrosis bronchiectasis. Invasive mechanical ventilation..

Factors affecting compliance with glove removal after contact with a patient or environment in four intensive care units

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