RESUMO
Acute Respiratory Distress Syndrome (ARDS) is understood as an inflammation-induced disruption of the alveolar endothelial-epithelial barrier that results in increased permeability and surfactant dysfunction followed by alveolar flooding and collapse. ARDS management relies on mechanical ventilation. The current challenge is to determine the optimal ventilatory strategies that minimize ventilator-induced lung injury (VILI) while providing a reasonable gas exchange. The data support that a tidal volume between 6-8 ml/kg of predicted body weight providing a plateau pressure < 30 cmH2O should be used. High positive end expiratory pressure (PEEP) has not reduced mortality, nevertheless secondary endpoints are improved. The rationale used for high PEEP argues that it prevents cyclic opening and closing of airspaces, probably the major culprit of development of VILI. Chest computed tomography has contributed to our understanding of anatomic-functional distribution patterns in ARDS. Electric impedance tomography is a technique that is radiation-free, but still under development, that allows dynamic monitoring of ventilation distribution at bedside.
Assuntos
Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/terapia , Impedância Elétrica , Humanos , Respiração com Pressão Positiva/métodos , Troca Gasosa Pulmonar , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/fisiopatologia , Mecânica Respiratória , Volume de Ventilação Pulmonar , Tomografia Computadorizada por Raios X , Lesão Pulmonar Induzida por Ventilação Mecânica/etiologia , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controleRESUMO
A 34-year old woman who developed persistent and severe acute respiratory distress syndrome with underlying myelomonocytic leukemia (M4FAB) is described. After ruling out the most common causes of pulmonary infiltration in this type of patient and one week of broad spectrum antibiotics and steroids therapy, we proposed leukemic pulmonary infiltration as etiological diagnosis. Despite using a protective ventilatory strategy, recruitment maneuvers, prone position and high frequency oscillatory ventilation, her gas exchange became worse. Under this condition we used a Pumpless-Extracorporeal life assist (PELA) and begun chemotherapy. The method, arterial blood gases, hemodynamic parameters and ventilatory mechanics before and after its use are described. The patient remained on P-ELA for nine days; one week later she was extubated and ten days after she was discharged from the Intensive Care Unit the patient left the hospital in good health condition.
Assuntos
Circulação Extracorpórea , Síndrome do Desconforto Respiratório/cirurgia , Adulto , Feminino , Humanos , Índice de Gravidade de DoençaRESUMO
BACKGROUND: The placement of intraabdominal polypropylene mesh entails risks of adhesions and fistulas that can be avoided by preperitoneal placement. METHODS: This comparative, open, experimental, prospective, randomized, and transversal study randomized pigs into two groups of 11 each for intraperitoneal (IPOM) or preperitoneal (TAPP) polypropylene mesh placement by laparoscopy. Diagnostic laparoscopy and tissue en-bloc resection was performed 28 days postoperatively for histopathologic analysis. RESULTS: The following data were observed for the two study groups: surgical time (IPOM: 35.73 +/- 4.22 min; TAPP: 58.09 +/- 6.28 min; p = or < 0.0001); adhesions (IPOM: 81.81%; TAPP: 27.27%; p = 0.032), grade III for IPOM and grade II for TAPP (p = 0.001); and interloop adhesions (IPOM: 81.81%; TAPP: 9.09%; p = 0.003). No fistulas were found in either group. The TAPP procedure showed better integration of mesh, without lesion to abdominal organs. Two complications, occurred with IPOM, and one with TAPP (p = 1.0, not significant). CONCLUSIONS: The perperitoneal technique requires more time, but has fewer adhesions and less intraabdominal inflammatory response. It is a feasible technique that may diminish risks in the laparoscopic treatment of incisional hernias with polypropylene mesh.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Hérnia Abdominal/cirurgia , Próteses e Implantes , Telas Cirúrgicas , Parede Abdominal , Animais , Feminino , Fibrose , Íleo/patologia , Laparoscopia , Modelos Animais , Polipropilenos , Estudos ProspectivosRESUMO
We performed a clinico-pathological study of 163 untreated cases of chronic hepatitis C. Eighty five percent of the patients were clinically asymptomatic and their physical examinations showed unremarkable or minimal changes at the time of the liver biopsy. Liver function tests tended to present slight abnormalities, involving mild elevations of the activity of the aminotransferases and gamma-glutamil transferase levels. In spite of these mild abnormalities, advanced chronic liver disease was histologically detected in eighty nine percent of the patients, mainly showing chronic active hepatitis. The most characteristic histological finding was an interlobular bile duct damage, which correlated with the presence of lymphoid aggregates in the portal tracts and with the development of fibrosis.
Assuntos
Hepatite C/patologia , Hepatite Crônica/patologia , Adulto , Idoso , Biópsia , Ensaios Enzimáticos Clínicos , Feminino , Antígenos de Superfície da Hepatite B/sangue , Hepatite C/diagnóstico , Anticorpos Anti-Hepatite C/sangue , Hepatite Crônica/diagnóstico , Humanos , Fígado/patologia , Cirrose Hepática/diagnóstico , Cirrose Hepática/patologia , Masculino , Pessoa de Meia-Idade , Transaminases/sangueRESUMO
To evaluate the efficacy of preoperative antibiotic prophylaxis, we studied 130 patients who were submitted to prostate surgery. These patients were divided into 3 groups. Overall morbidity was lower for the patient group that had received antibiotic prophylaxis (Netilmicin, 3 doses) than for the group on placebo and the group on antibiotics postoperatively. The incidence of significant bacteriuria for the group on Netilmicin was less at 7 days (7.5%) and at 30 days (20.5%) than for the other groups: (22.55%) and (49.36%) at 7 and 30 days, respectively. The foregoing data indicate that preoperative antibiotic prophylaxis should be used for periods less than 24 h in all noninfected patients undergoing prostate surgery. The cost of antibiotic therapy, presence of opportunistic organisms and the duration of hospital stay are reduced by antimicrobial prophylaxis.