Background: The utilization of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for immunoadsorption has proven efficacious in reducing mortality rates among neonatal and pediatric patients afflicted with severe sepsis and septic shock. However, the effectiveness of this treatment in adult patients with septic shock remains controversial. Objective: This study was designed to assess the potential of VA-ECMO as an immunoadsorption therapy in patients with severe sepsis and septic shock. The primary objective of this study is to evaluate the efficacy of VA-ECMO in improving clinical outcomes, including acute respiratory distress syndrome (ARDS) and ventilator-associated pneumonia (VAP), weaning from mechanical ventilation, the length of intensive care unit (ICU) stay, and mortality rates in patients with concurrent severe pulmonary contusions, septic shock, and respiratory failure resulting from ARDS and VAP. Methods: This study enrolled a cohort of 100 adult patients with severe pulmonary contusions resulting in persistent respiratory failure despite ten days of mechanical ventilation. These patients subsequently developed severe sepsis, VAP with ARDS presentation, and high Murray score (>3 points), Sequential Organ Failure Assessment (SOFA) score (> 12 points), and Clinical Pulmonary Infection Score (CPIS) (> 6 points). The patients were then divided into two groups: group A (n = 50) received conventional management, while group B (n = 50) underwent VA-ECMO. Moreover, the outcomes, including improvement in ARDS and VAP, successful weaning from mechanical ventilation, length of ICU stay, improvement of one or all parameters of Murray, SOFA, and CPIS scores, morbidity rate, and mortality rate were compared between the two groups and recorded after 14 days of treatment. Results: This study revealed that patients in group B showed significant improvement in Murray, SOFA, and CPIS scores. Furthermore, a large percentage of patients in group B were successfully weaned from both inotropic support and mechanical ventilation and were discharged from ICU. However, no significant difference in the mortality rate was observed between the two groups. Conclusion: VA-ECMO notably impedes the progression of sepsis, shortens ICU stay, and expedites the weaning from inotropic support and mechanical ventilation. However, it has no impact on the mortality rate of adult patients with septic shock.
Introduction: Re-intubation and re-ventilation after complete weaning of patients with prolonged ventilation are considered a major problem in ICU. The re-intubation in such patients associated with higher mortalities prolongs the duration of ICU stay. The mortality rate in those patients may exceed 40% in some studies. Aims: The study aimed to compare and evaluate the effect of use of two new maneuvers with control after fulfilling criteria of weaning from prolonged ventilation, either immediate use of NIV post-extubation and every 12 hours for 24 hours or MV for one hour on both re-intubation and ICU discharge of traumatic ARDS patients who ventilated for one week or more. Materials and Methods: It is a prospective double-blind study done on total 300 patients, admitted with respiratory failure ARDS due to severe lung contusion. All of them were selected to be ventilated for > one week. All of them fulfilled the criteria of weaning at the end of the studied period. Patients were randomly allocated in three groups; each group contained 100 patients. Group A was considered the control group. They extubated and followed our routine protocol; patients of group B used our first new maneuver and reconnected to mechanical ventilation before extubation for one hour, while patients of group C used our second new maneuver; patients of this group extubated and immediately connected to NIV with BIPAP mode for 1 hour every 12 hours for 24 hours. Results: There was a significant reduction in the number of patients who experienced deterioration in conscious level throughout the study in patients of both groups B and C compared to group A. Also, a significant reduction was seen in the number of patients who experienced deterioration in clinical parameters of respiration, of both groups B and C compared to group A with regard to high respiratory rate, desaturation and development of hyperdynamic circulation (tachycardia and hypertension). Also, a significant reduction was seen in the number of patients who had multiple quadrant parenchymatous infiltration throughout the study in patients of both groups B and C compared to group A. significant reduction in the number of patients marked limitation to FEV1, FVC and MVV in patients of both groups B and C compared to group A. Conclusion: Use of either immediate NIV every 12 hours for 24 hours or MV for one hour after fulfillment of weaning criteria reduced reintubation, re-ventilation and post-extubation respiratory failure and decreased the ICU stay in prolonged ventilated patients due to ARDS from severe lung trauma with no significant difference between them.
Introduction: Off-labelled use of activated Factor VII (aFVII) in severe traumatic bleeding has been used as an alternative to aminocaproic. Aim of Work: The aim of this study is to compare the efficacy of aFVII with aminocaproic acid in the medical treatment of retroperitoneal bleeding, treatment of hypovolemic shock and preventing complications of massive blood transfusion. Materials and Methods: 80 patients with traumatic retro-peritoneal hematoma were allocated into two groups of 40 patients each. Patients in Group A received aminocaproic acid, while patients of group B received aFVII. The number of packed RBCs given to achieve the target Hb level and time to get to this target Hb level (>10 gm%) were recorded as indicators of control bleeding. Blood pressure, pulse, arterial blood gasses and urine output were recorded as indicators of successful treatment of hypovolemic shock. Hypoxic index, chest X-ray and coagulation profile were used as indicators for complications. Results: There was a significantly smaller number of packed RBCs given to patients of group B to achieve the target Hb level and this target Hb level was achieved in a shorter time. There was a significantly higher number of patients in group B compared to group A who had normal blood pressure, pulse and urine output, pH and bicarbonate concentration. There was a significantly smaller number of patients who developed DIC and TRALI in group B compared to group A. Conclusion: aFVII was more effective than aminocaproic acid and needed a shorter time to stop retroperitoneal bleeding, treat hypovolemic shock, restore adequate tissue perfusion and protect patients from complications of massive blood transfusion.
Introduction: Corticosteroids are used in ARDS to prevent lung fibrosis. The best dose, duration and regimen are still the points of debate among physicians. Aim of the Work: The aim of this study is to make a comparison between two corticosteroid regimens, i.e. short-duration high dose versus long- duration low dose corticosteroid use in ARDS due to lung contusion with VAP for lowering both morbidity and mortality rates and early weaning from ventilator. Patients and Methods: Patients who had >3 on Murray score and >6 on CPIS were allocated randomly in two groups of 120 patients each. Group A received 30 mg/kg methyl-prednisolone slowly intravenously in 250 ml normal saline every 8 hours for only 48 hours, while group B received 1 mg/kg/day methyl-prednisolone divided into three doses given every 8 hours for two weeks. The study lasted for 16 days; morbidity was considered if no improvement was observed in any or all clinical parameters of both Murray and CPIS scores and if there was failure in removing patients from the ventilator within the studied period. Results: Significant improvement was observed in patients of group B compared to group A with regard to APACH II <10 score, arterial oxygen saturation>95, hypoxic index >300, lung infiltrate in chest X-ray, lung compliance, response of the lung to recruitment maneuver, the return of core temperature to normal, normal tracheal secretion, the return of leucocytic count to normal, negative qualitative sputum culture and a significantly higher number of patients were removed from the ventilator of group B compared to group A. However, mortality rate was not significant between the two groups. Conclusion: Low dose corticosteroid if used for a long duration significantly lowers morbidity and accelerates recovery, and in turn, accelerates weaning from ventilator compared to high dose corticosteroid used for a short duration. While the difference between the two regimens was not significant with regard to the mortality rate, still further studies are needed to emphasize a fixed corticosteroid dose and regimen in ARDS due to lung contusion.
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