Acute Respiratory Distress Syndrome (ARDS) is a condition of varied etiology characterized by the acute onset (within 1 week of the inciting event) of hypoxemia, reduced lung compliance, diffuse lung inflammation and bilateral opacities on chest imaging attributable to noncardiogenic (increased permeability) pulmonary edema. Although multi-organ failure is the most common cause of death in ARDS, an estimated 10-15% of the deaths in ARDS are caused due to refractory hypoxemia, i.e.- hypoxemia despite lung protective conventional ventilator modes. In these cases, clinicians may resort to other measures with less robust evidence -referred to as "salvage therapies". These include proning, 48 h of paralysis early in the course of ARDS, various recruitment maneuvers, unconventional ventilator modes, inhaled pulmonary vasodilators, and Extracorporeal membrane oxygenation (ECMO). All the salvage therapies described have been associated with improved oxygenation, but with the exception of proning and 48 h of paralysis early in the course of ARDS, none of them have a proven mortality benefit. Based on the current evidence, no salvage therapy has been shown to be superior to the others and each of them is associated with its own risks and benefits. Hence, the order of application of these therapies varies in different institutions and should be applied following a risk-benefit analysis specific to the patient and local experience. This review explores the rationale, evidence, advantages and risks behind each of these strategies.
Introduction: Cardiogenic shock that results from pulmonary embolus has a high mortality rate. Systemic thrombolysis is frequently used in submassive and massive pulmonary embolus and has been shown to restore circulation. However, in the event of impending or ongoing cardiac arrest, systemic thrombolysis or anticoagulation alone has not been always shown to be effective. Case reports have previously established that extracorporeal membrane oxygenation can effectively be used as an effective rescue strategy in cases of cardiac arrest as a result from massive pulmonary embolus. We report six cases of massive pulmonary embolism (PE), in which veno-arterial extracorporeal membrane oxygenation (VA ECMO) was utilized or used as a backup strategy with excellent outcomes. We highly recommend using this strategy at the bedside in a tertiary care facility where VA ECMO support is available.
Methods: This is a retrospective study of all patients that underwent VA ECMO or utilized VA ECMO at the bedside as a rescue strategy in the setting of massive PE. We abstracted relevant clinical information from patient charts for this review.
Results and analysis: Out of the 107 VA ECMO runs performed at our facility between 1 September 2013 and 31 December 2014, four patients utilized this strategy in the setting of massive PE with impending cardiac arrest; in two cases it was available to use as a backup strategy. All six patients (Table 1) had successful recovery with complete restoration of cognitive status, functional status, and without any clinical signs of right ventricular (RV) dysfunction on discharge.
BACKGROUND Labour pains are said to be very intense for many women. They may adversely affect both mother and foetus. A variety of techniques are available to offer labour analgesia. Of all techniques, continuous epidural analgesia has gained popularity as a safe and effective technique of pain relief in labour. This study was undertaken to compare the effect of 0.125% bupivacaine hydrochloride alone versus 0.125% bupivacaine hydrochloride with 25 µgms fentanyl citrate given epidurally for labour analgesia.
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