BACKGROUND:Although a strategy of tidal volume (V(t)) reduction during the one-lung ventilation (OLV) period is advised in thoracic surgery, the influence of the pre-operative respiratory status on the tolerance of this strategy remains unknown. Therefore, the aim of this study was to compare the pulmonary function between chronic obstructive pulmonary disease (COPD) and healthy-lung patients during the operative and the post-operative period.METHODS:Forty-eight patients undergoing a planned lobectomy for cancer and presenting either a healthy lung function (n=24) or a moderate COPD stage (n=24) were ventilated without external positive end-expiratory pressure (PEEP) and received 9 ml/kg V(t) during the two-lung ventilation (TLV) period, secondary reduced to 6 ml/kg during the OLV period. Lung function was assessed by peroperative gas exchange, venous admixture, respiratory mechanical parameters and post-operative spirometric measurements.RESULTS:Although the PaO(2) was superior in the healthy-lung group during the TLV, once the OLV was established, no difference was observed between the two groups. Moreover, the PaO(2)/FiO(2) was proportionally more impaired in the healthy-lung group compared with the COPD group (50 ± 13 vs. 72 ± 19% of the baseline values after exclusion and 32 ± 15 vs. 51 ± 25% after the thoracotomy, P<0.05 for each) as well as the venous admixture. In the post-operative period, a higher decrease was observed in the healthy-lung group for the forced vital capacity and the forced expiratory volume.CONCLUSIONS:Reducing V(t) to 6 ml/kg without the adjunction of external PEEP during OLV is associated with better preservation of lung function in the case of moderate COPD than in the case of healthy-lung status.

Objective. - Assessment of haemodynamic, respiratory and renal effects of hypertonic saline-hydroxyethyl starch (HyperHES (R)) in critically ill-patients with hemorrhagic shock.Patients and methods. - Seventeen mechanically ventilated patients with hemorragic shock benefiting from a cardiovascular monitoring by PiCCO device and requiring rapid volume loading. Two hundred and fifty milliliters of HyperHES (R) were given over 5 minutes.The efficacy of volume loading was assessed by the measure of the systolic arterial pressure (SAP), cardiac index (Cl), stroke volume variation (SVV) and the indexed systemic vascular resistance (iSVR). Studied parameters were assessed at baseline, 5, 30, 60 and 180 minutes after the end of HyperHES (R) infusion.Results. - SAP (105 +/- 23 vs 77 +/- 10; p < 0.001) and CI (4.8 +/- 1.1 vs 3.5 +/- 0.9; p < 0.001) were significantly increased whereas iSVR (1175 +/- 310 vs 1501 +/- 337; p < 0.01) and SVV (13 +/- 7 vs 20 +/- 5; p < 0.01) were significantly decreased 5 minutes after the HyperHES infusion. Sodium (145 6 vs 136 5; p < 0.001) and chloride (1118 7 vs 107 6: p < 0.001) were increased 5 minutes after the infusion. The PaO(2)/FiO(2) ratio as the extravascular lung water was not influenced by the infusion. The follow-up of renal parameters during the three first days (creatinemia, uremia and diuresis) did not revelead significant variations.Conclusion. - In patients with hemorrhagic shock, the infusion of hypertonic saline (7.5%) hydroxyethyl starch association was followed by an increase in SAP, Cl serum sodium and chloride concentrations. Study design. - Prospective observational study. (C) 2009 Elsevier Masson SAS. All rights reserved.

OBJECTIVE:Assessment of haemodynamic, respiratory and renal effects of hypertonic saline-hydroxyethyl starch (HyperHES) in critically ill-patients with hemorrhagic shock.PATIENTS AND METHODS:Seventeen mechanically ventilated patients with hemorragic shock benefiting from a cardiovascular monitoring by PiCCO device and requiring rapid volume loading. Two hundred and fifty milliliters of HyperHES were given over 5 minutes. The efficacy of volume loading was assessed by the measure of the systolic arterial pressure (SAP), cardiac index (CI), stroke volume variation (SVV) and the indexed systemic vascular resistance (iSVR). Studied parameters were assessed at baseline, 5, 30, 60 and 180 minutes after the end of HyperHES infusion.RESULTS:SAP (105 + or - 23 vs 77 + or - 10; p<0.001) and CI (4.8 + or - 1.1 vs 3.5 + or - 0.9; p<0.001) were significantly increased whereas iSVR (1175 + or - 310 vs 1501 + or - 337; p<0.01) and SVV (13 + or - 7 vs 20 + or - 5; p<0.01) were significantly decreased 5 minutes after the HyperHES infusion. Sodium (145 + or - 6 vs 136 + or - 5; p<0.001) and chloride (118 + or - 7 vs 107 + or - 6; p<0.001) were increased 5 minutes after the infusion. The PaO(2)/FiO(2) ratio as the extravascular lung water was not influenced by the infusion. The follow-up of renal parameters during the three first days (creatinemia, uremia and diuresis) did not revelead significant variations.CONCLUSION:In patients with hemorrhagic shock, the infusion of hypertonic saline (7.5%) hydroxyethyl starch association was followed by an increase in SAP, CI serum sodium and chloride concentrations.STUDY DESIGN:Prospective observational study.

Les complications respiratoires sont la principale cause de complication médicale après chirurgie de résection de l’œsophage. Les facteurs favorisant leur développement sont présents dès la période préopératoire et doivent être dépistés. La stratégie de ventilation mécanique durant la procédure chirurgicale est désormais reconnue comme un facteur de risque indépendant. Des données préliminaires indiquent qu’une amélioration de la fonction respiratoire pourrait être obtenue par l’emploi de stratégies basées sur la réduction du volume courant et l’adjonction d’une PEP durant la période de ventilation monopulmonaire. Les thérapeutiques utilisées lors de la survenue des complications respiratoires comprennent le maintien d’une analgésie optimale, d’une kinésithérapie active et l’emploi de la ventilation non invasive sans risque de désunion anastomotique. L’intrication des complications médicales et chirurgicales doit constamment faire rechercher une désunion anastomotique lors d’une détresse respiratoire.

STUDY OBJECTIVE:In order to assess the effects of inhaled nitric oxide (iNO) in preventing early-onset lung edema from occurring after lung transplantation, we measured extravascular lung water (EVLW) in a group of lung transplant recipients who were at high risk for developing ischemia-reperfusion-induced lung injury.DESIGN:Prospective, randomized study.SETTINGS:Surgical ICU in a teaching hospital.PATIENTS:Thirty double-lung transplant recipients.INTERVENTIONS:Patients were randomized to receive or not receive 20 ppm iNO at the time of reperfusion (ie, before any occurrence of lung edema). In the NO group, iNO was then administered for a 12-h period. A double-dilution technique was used for the serial assessment of EVLW, intrathoracic blood volume, and cardiac index. Standard hemodynamic and pulmonary parameters were also recorded during the first 3 postoperative days.MEASUREMENTS AND RESULTS:Patients who received iNO did not have a different lung water content compared to control subjects (p = 0.61 [by analysis of variance (ANOVA)]). Blood oxygenation (ie, Pao(2)/fraction of inspired oxygen [Fio(2)] ratio) did not differ between the two groups (p = 0.61 [by ANOVA]). In both groups, EVLW and Pao(2)/Fio(2) ratio dropped significantly over time, regardless of the use of iNO (p < 0.01 [by ANOVA]).CONCLUSIONS:In the population studied, prophylactic iNO that was administered at 20 ppm had no effect on pulmonary edema formation and resolution following lung transplantation.

OBJECTIVE:Prospective analysis of endovascular management of traumatic isthmic rupture with second generation stent grafts.STUDY DESIGN:Prospective analysis and follow-up.PATIENTS:Ten consecutive multiple injured patients presenting an acute isthmic traumatic rupture who underwent an endovascular repair with second generation stent grafts.METHODS AND RESULTS:The aortic injury was diagnosed by spiral computed tomography scan. The appropriate time to repair was decided according to multidisciplinary decision after analysis of associated injuries status and mediastinal lesions evolution. Endovascular repair was successfully completed in all patients under general anaesthesia without requirement of haemodynamic manipulations. Despite a prolonged length of stay related to associated injuries, all patients were discharged from hospital without migration of devices or complication related to the endovascular procedure. After a 20 months follow-up (range 6 - 38 months), all patients were alive with a satisfactory CT scan analysis.CONCLUSION:The immediate availability of the second generation of stents-grafts allowed the endovascular treatment of isthmic rupture without haemodynamic manipulations or massive heparinization. The analysis of this selected series reinforces the interest of this non-invasive technique for anaesthetists especially in polytraumatized patients.

Objective. To investigate N-terminal pro- brain natriuretic peptide (NT-proBNP) level as a prognostic factor and a marker of myocardial dysfunction in patients with septic shock.Design: Prospective observational study.Setting. Intensive care unit.Subjects: A total of 39 patients diagnosed with septic shock and requiring mechanical ventilation.Measurements and Main Results: Demographic, hemodynamic, respiratory, and biological data (notably NT-proBNP, lactate, and cardiac troponin 1) were collected at inclusion and every 12 hrs. The independent factors for death were higher Sequential Organ Failure Assessment score in the 24-hr period after inclusion (odds ratio, 4.7; 95% confidence interval, 1.15-19.3) and the highest NT-proBNP level in the 24-hr period after inclusion (odds ratio, 1.12 per 1000 pg/mL increase; 95% confidence interval, 1.05-1.26). An NT-proBNP of > 13,600 pg/mL predicted intensive care unit mortality with an accuracy of 77%. Area under the receiver operating characteristic curve was 0.8 (p =.002; 95% confidence interval, 0.66-0.93). NT-proBNP levels were over the accepted normal range in all patients. Values were highest between 24 and 36 hrs after onset of septic shock and were significantly higher in nonsurvivors at each time between inclusion and day 7. The lowest left ventricular stroke work index of the first 24-hr period after inclusion was the only factor that independently influenced higher NT-proBNP levels at the same time (odds ratio, 0.91; 95% confidence interval, 0.84-0.98).Conclusion. NT-proBNP seems to be an early factor of prognosis and myocardial dysfunction in patients with septic shock.

BACKGROUND One-lung ventilation-related hypoxaemia (OLV-RH) can occur in patients with healthy lungs. In this case, PEEP frequently improves oxygenation. The aim of this study was to determine, in a healthy lung model of OLV, whether the increase in PEEP improved oxygenation and whether the mechanisms involved include both inspiratory lung recruitment and an end-expiratory lung volume increase. Since inhaled nitric oxide (iNO) may have a synergistic effect on oxygenation in the case of PEEP-induced recruitment, their association was also tested. METHODS Twenty pigs were studied during open-chest, left OLV. Arterial blood gases and haemodynamic variables were measured at different levels of PEEP (0, 5, 10 and 15 cm H(2)O) applied in random order with or without iNO 4 p.p.m. Pressure-volume curves were measured at each level of PEEP. RESULTS PEEP(5) and PEEP(10) improved Pa(O(2))/FI(O(2)) ratio (P<0.005) and shunt (P<0.005) regardless of the presence of iNO. PEEP(15) improved oxygenation and shunt only when it was associated with iNO (P<0.001). Whereas PEEP(5), PEEP(10) and PEEP(15) were associated with a significant increase in end-expiratory volume (P<0.001), only PEEP(5) and PEEP(10) were associated with continuous lung volume recruitment (P<0.01). Moreover, PEEP(15) induced a significant decrease in linear compliance (P<0.001). CONCLUSIONS In a healthy porcine lung model of OLV-RH, moderate PEEP can improve oxygenation. This effect implies both expiratory and inspiratory pulmonary recruitment. Co-administration of 4 p.p.m. iNO was ineffective.

To prospectively evaluate the prognostic values of two serum cytokine levels, TNFα and IL 6 serially measured at predetermined intervals in septic shock patients unresponsive to correction of hypoxaemia and plasma volume expansion and treated according to a strict protocol designed to meet specific therapeutic goals (goal-directed therapy). The evolution of serum lactate levels and oxygen-derived parameters was also investigated.

Objective: Prospective analysis of endovascular management of traumatic isthmic rupture with second generation stent grafts.Study design: Prospective analysis and follow-up.Patients. - Ten consecutive multiple injured patients presenting an acute isthmic traumatic rupture who underwent an endovascular repair with second generation stent grafts.Methods and results. - and results: The aortic injury was diagnosed by spiral computed tomography scan. The appropriate time to repair was decided according to multidisciplinary decision after analysis of associated injuries status and mediastinal lesions evolution. Endovascular repair was successfully completed in all patients under general anaesthesia without requirement of haemodynamic manipulations. Despite a prolonged length of stay related to associated injuries, all patients were discharged from hospital without migration of devices or complication related to the endovascular procedure. After a 20 months follow-up (range 6 - 38 months), all patients were alive with a satisfactory CT scan analysis.Conclusion. - The immediate availability of the second generation of stents-grafts allowed the endovascular treatment of isthmic rupture without haemodynamic manipulations or massive heparinization. The analysis of this selected series reinforces the interest of this noninvasive technique for anaesthetists especially in polytraumatized patients. (c) 2005 Publie par Elsevier SAS.

Objective: The double indicator method is sensitive to alterations in the distribution of pulmonary blood flow. This distribution is influenced by the type of lung injury. The aim of this study was to compare measurements of lung water by the double indicator method with measurements obtained by gravimetry in a direct lung injury model induced by tracheal instillation of hydrochloric acid and in an indirect lung injury model induced by the intravenous injection of oleic acid.Design: Prospective, randomized laboratory study. Setting: Animal research laboratory.Subjects: Forty-two female pigs (28 +/- 3 kg).Interventions: Pigs were anesthetized and ventilated and were allocated into three groups: control (n = 6), hydrochloric acid (4 mL/kg intratracheally, n = 24), or oleic acid (0.1 mL/kg intravenously, n = 12).Measurements and Main Results. Hydrochloric acid instillation or oleic acid injection resulted in a similar hypoxemia and induced a two- to three-fold increase in extravascular lung water (EVLW) by gravimetry (EVLWG) at 3 hrs compared with controls. In the oleic acid group, there was a significant correlation between EVLWG and EVLW by double indicator method (EVLWDI; r = .88, p < .0001). The bias for EVLWDI - EVLWG measurements was -5.2 mL/kg (95% confidence interval, -5.7 to -4.7 mL/kg) with 95% limits of agreement of -7 to -3.4 mL/kg. In the hydrochloric acid group, there was no significant correlation between EVLWDI and EVLWG values, and the double indicator method failed to detect pulmonary edema in 65% of the animals (EVLWDI <8 mL/kg). The bias was -7.9 mL/kg (95% confidence interval, -9.3 to -6.5 mL/kg) with 95% limits of agreement of -14.4 to -1.4 mL/kg.Conclusions: The double indicator method is useful for evaluation of pulmonary edema in indirect lung injury, as induced by oleic acid, but produces misleading values in direct lung injury, as produced by hydrochloric instillation.

Background: Cytomegalovirus (CMV) frequently is observed in immunocompromised hosts. The aim of this study was to report cases of ventilator-associated CMV pneumonia diagnosed by pathologic examination in intensive care patients without acquired immunodeficiency syndrome or hematologic malignancy or who were not receiving immunosuppressive agents.Methods: From June 1, 1989, to May 31, 1994, 2,785 patients were hospitalized. During the study period, 60 autopsies and 26 open-lung biopsies were performed in nonimmunocompromised patients who were seen with acute respiratory failure and/or symptoms suggestive of ventilator-associated pneumonia. Cytomegalovirus pneumonia was diagnosed using pulmonary samples by the identification of large cells with large nuclei containing a basophilic or eosinophilic inclusion surrounded by a light halo. These typical findings always were associated with a diffuse interstitial pneumonitis,Results: Cytomegalovirus pneumonia was diagnosed after histologic examination in 25 patients. The reason for admission to the intensive care unit was major surgery in 13 patients and medical problems in 12 patients. Ventilator-associated CMV pneumonia was diagnosed by histologic examination 22.4 +/- 8.8 days after admission to the intensive care unit (median 18 days; range 10-40 days). The clinical description was similar with the 25 patients who were seen with ventilator-associated CMV pneumonia and the 61 patients without ventilator-associated CMV pneumonia. However, there was a more severe hypoxemia (72 +/- 16 vs, 95 +/- 41 mm Hg, P < 0.05) and a higher Weinberg's radiologic score (9.2 +/- 1.9 vs. 7.4 +/- 2.7, P < 0.05) in the ventilator-associated CMV pneumonia group, Diagnosis of ventilator-associated CMV pneumonia was made for 9 of 17 patients when shell-vial culture technique using fluorescein-labeled antibody E 13 was performed on bronchoalveolar lavage products. Four of the eight patients treated by ganciclovir therapy died of multiple organ dysfunction syndrome.Conclusions The diagnosis of ventilator-associated CMV pneumonia should not be excluded in intensive care patients, even those without acquired immunodeficiency syndrome, hematologic malignancy, or immunosuppressive agents on admission.

Objective: To compare the temperature and humidification output of one heated humidifier system (Bennett Cascade 2 Humidifier) and two heat and moisture exchangers (Pall Ultipor, BB 50, and Humid-Vent Filter) in intensive care unit (ICU) patients submitted to a minute ventilation of > 10 L/min.Design: Prospective, controlled, randomized, unblinded study.Setting: ICU of a university hospital.Patients: Eleven sedated and paralyzed patients who required controlled mechanical ventilation with a minute ventilation of > 10 L/min for > 3 days.Interventions: After a randomized selection process, the patients were ventilated for 24-hr periods with the humidifier and one of the heat and moisture exchangers. Both heat and moisture exchangers were first tested for 45 mins; then, the heat and moisture exchanger that demonstrated the best performance in terms of temperature and water preservation was tested for 24 hrs.Measurements and Main Results: During the inspiration phase for each patient, the following measurements were performed: mean and minimum values of temperature, relative and absolute humidity of inspired gases. During the 45-min test period, the Humid-Vent Filter had a better temperature and humidification output than the Pall Ultipor Filter and thus was tested for 24 hrs. The Bennett Cascade 2 Humidifier and the Humid-Vent Filter had a better thermic capacity than the Pall Ultipor Filter (p < .001). No difference was ever observed between the Bennett Cascade 2 Humidiifier and the Humid-Vent Filter regarding relative humidity. The Pall Ultipor Filter had a lower temperature and humidification output when compared with the other two systems (p < .007). Concerning absolute humidity of inspired gases, the Pall Ultipor Filter achieved a lower performance than any other tested systems (p < .02). A small but significant decrease in temperature and absolute humidity, but not in relative humidity, was seen after 24 hrs of use with the Humid-Vent Filter. However, with this heat and moisture exchanger, all patients had an absolute humidity of > 28 mg H2O/L and a relative humidity of > 93% after 24 hrs of use.Conclusions: In patients with a minute ventilation of > 10 L/min (> 10.5 to 16.0 L/min), the Humid-Vent Filter had a temperature and humidification output close to the reference system (the Bennett Cascade 2 Humidifier). The Pall Ultipor Filter had a significantly lower temperature and humidification output in these patients.

The effects of propofol on right ventricular function were studied in 11 ICU patients who needed sedation for acute respiratory failure or neurological diseases. Right ventricular function was studied using a thermodilution method at patients' bedside. Right ventricular ejection fraction (RVEF), cardiac output (CO), right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), right ventricular end-systolic pressure (RVESP) and pulmonary capillary wedge pressure (PCWP) were obtained from a modified Swan-Ganz catheter. Calculation of right ventricular end-systolic pressure-volume relation (ESPVR) allowed to assess changes in right ventricular inotropic state. A baseline ESPVR was obtained before propofol infusion: RVESP = 0.21 RVESV + 2.4, r = 0.83, P < 0.0001. Then, patients were given an induction dose of 1 to 2.5 mg.kg-1 propofol over 1 min followed by a continuous infusion of 3 mg.kg-1.h-1. During propofol infusion heart rate, mean arterial pressure, PCWP, CO, systemic vascular resistance and RVEF significantly decreased. No change in RVEDV and RVESV was observed. ESPVR was significantly altered with a dramatic decrease in the slope of the relation: RVESP = 0.12 RVESV + 6.9 (P < 0.001 from baseline). Dobutamine was used in five patients with clinically significantly cardiac dysfunction and restored the slope of the ESPVR to the baseline value: RVESP = 0.22 RVESV + 6.3 (NS from baseline). In the study patients, propofol altered the inotropic state of the right ventricle.

Tracheal rupture from within is uncommon and always iatrogenic. We report a case of a tracheal rupture following the use of a Sengstaken-Blakemore tube to control a gastroesophageal hemorrhage. Emergency surgical repair was required. Although complications associated with balloon tamponade are well-documented, no major tracheal injury has ever been reported.

We have studied the effects of bolus doses of midazolam 0.15 mg kg-1 i.v. on intracranial pressure (ICP), mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) in 12 patients with severe head injury (Glasgow Coma Scale score < or = 6). The study was performed in patients aged 17-44 yr who were sedated (phenoperidine 20 micrograms kg-1 h-1) and paralysed (vecuronium 2 mg h-1). Midazolam reduced MAP from 89.0 mmHg to 75.0 mmHg (P < 0.0001), while CPP decreased from 71.0 mmHg to 55.8 mmHg (P < 0.0001). During the study, CPP decreased to less than 50 mmHg in four patients. Midazolam induced small, non-significant changes in ICP. However, when control ICP was less than 18 mmHg (n = 7 patients), an increase in ICP was observed. The remaining five patients (control ICP > or = 18 mmHg) exhibited a slight decrease in ICP. These findings suggest that bolus administration of midazolam should be performed with great caution in patients with severe head injury, especially when ICP is less than 18 mmHg.

STUDY OBJECTIVE:To compare the ability of dopamine and norepinephrine to reverse hemodynamic and metabolic abnormalities of human hyperdynamic septic shock.DESIGN:Prospective, double-blind, randomized trial.SETTING:An ICU in a university hospital.PATIENTS:Adult patients with hyperdynamic septic shock after fluid resuscitation.INTERVENTIONS:Patients were assigned to receive either dopamine (2.5 to 25 micrograms/kg/min) or norepinephrine (0.5 to 5.0 micrograms/kg/min). If hemodynamic and metabolic abnormalities were not corrected with the maximum dose of one drug, the other was added.MEASUREMENTS AND RESULTS:The aim of therapy was to achieve and maintain for at least 6 h all of the following: (1) systemic vascular resistance index > 1,100 dynes.s/cm5.m2 and/or mean systemic blood pressure > or = 80 mm Hg; (2) cardiac index > or = 4.0 L/min/m2; (3) oxygen delivery > 550 ml/min/m2; and (4) oxygen uptake > 150 ml/min/m2. With the use of dopamine 10 to 25 micrograms/kg/min, 5 of 16 patients (31 percent) were successfully treated, as compared with 15 of 16 patients (93 percent) by norepinephrine at a dose of 1.5 +/- 1.2 micrograms/kg/min (p < 0.001). Ten of 11 patients who did not respond to dopamine and remained hypotensive and oliguric were successfully treated with the addition of norepinephrine.CONCLUSIONS:At the doses tested, norepinephrine was found, in the present study, to be more effective and reliable than dopamine to reverse the abnormalities of hyperdynamic septic shock. In the great majority of the study patients, norepinephrine was able to increase mean perfusing pressure without apparent adverse effect on peripheral blood flow or on renal blood flow (since urine flow was reestablished). At the same time, oxygen uptake was increased.