Objective Global lung stress varies considerably with low tidal volume ventilation for acute respiratory distress syndrome (ARDS). High stress despite low tidal volumes may worsen lung injury and increase risk of death. No widely available parameter exists to assess global lung stress. We aimed to determine whether the volume delivered during a recruitment maneuver (VRM) is inversely associated with lung stress and mortality in ARDS. Design Substudy of an ARDS clinical trial on esophageal pressure-guided PEEP titration. Setting U.S. academic medical center. Patients 42 patients with ARDS in whom airflow, airway pressure, and esophageal pressure were recorded during the recruitment maneuver (RM). Interventions A single RM was performed before initiating protocol-directed ventilator management. RMs consisted of a 30-second breath hold at 40 cmH2O airway pressure under heavy sedation or paralysis. VRM was calculated by integrating the flow-time waveform during the maneuver. End-inspiratory stress was defined as the transpulmonary (airway minus esophageal) pressure during end-inspiratory pause of a tidal breath, and tidal stress as the transpulmonary pressure difference between end-inspiratory and end-expiratory pauses. Measurements and Main Results VRM ranged between 7.4 and 34.7 mL/kg predicted body weight (PBW). Lower VRM predicted high end-inspiratory and tidal lung stress (end-inspiratory: ß = −0.449, 95% CI −0.664 to −0.234; p < .001; tidal: ß = −0.267, 95% CI −0.423 to −0.111; p = .001). After adjusting for PaO2/FIO2 and either driving pressure, tidal volume, or plateau pressure and PEEP, VRM remained independently associated with both end-inspiratory and tidal stress. In unadjusted analysis, low VRM predicted increased risk of death (OR 0.85, 95% CI 0.72–1.00; p = .026). VRM remained significantly associated with mortality after adjusting for study arm (OR 0.84, 95% CI 0.71–1.00; p = .022). Conclusions Low VRM independently predicts high lung stress and may predict risk of death in patients with ARDS.
Our case and review highlight the potential risk factors for S. marcescens necrotizing fasciitis, including underlying renal disease and open wounds, and demonstrate the emergence of this organism as a cause of severe, life-threatening soft tissue infections.
Introduction:There are few data on the safety and efficacy of laser photoselective vaporization (LVP) in elderly men. We compared the safety and efficacy of LVP for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men ≥75 years, who we defined as elderly, to those <75 years.Materials and Methods:Safety and efficacy outcomes in elderly men undergoing LVP for lower urinary tract symptoms secondary to BPH from 2005 to 2012 were compared with men <75 years. Differences between-groups in demographics, perioperative outcomes, complications, and postoperative changes in International Prostate Symptom Score (I-PSS) were calculated.Results:Of 202 patients, 49 (24%) were elderly (range: 75-95 years) and 153 (76%) were <75 years. Preoperatively, elderly men were more likely to have heart disease (35% vs. 20%, P = 0.03), gross hematuria (6.1% vs. 0.7%, P = 0.05), urinary retention (57% vs. 41%, P = 0.07), and take anti-coagulants (61% vs. 35%, P = 0.002). Elderly men had a longer median length of stay (1 day vs. 0 day, P = 0.001). There were no significant between-group differences in transfusion frequency (4.4% vs. 0.7%, P = 0.14) or Clavien III complications (2% vs. 2.6%, P = 1.0). One month postsurgery, elderly patients reported smaller median decreases in I-PSS (5.5 vs. 9, P = 0.02) and urinary bother (1 point vs. 2, P = 0.03) compared with preoperative values. At till 9 months follow-up, there were no significant between-group differences in median I-PSS or urinary bother scores.Conclusions:Despite a higher prevalence of preoperative comorbidity and urinary retention, elderly LVP patients experienced perioperative safety and shorter term efficacy outcomes comparable to younger men.
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