Optimal pharmacological management during extracorporeal membrane oxygenation (ECMO) involves more than administering drugs to reverse underlying disease. ECMO is a complex therapy that should be administered in a goal-directed manner to achieve therapeutic endpoints that allow reversal of disease and ECMO wean, minimisation of complications (treatment of complications when they do occur), early interruption of sedation and rehabilitation, maximising patient comfort and minimising risks of delirium. ECMO can alter both the pharmacokinetics (PK) and pharmacodynamics (PD) of administered drugs and our understanding of these alterations is still evolving. Based on available data it appears that modern ECMO circuitry probably has a less significant impact on PK when compared with critical illness itself. However, these findings need further confirmation in clinical population PK studies and such studies are underway. The altered PD associated with ECMO is less understood and more research is indicated. Until robust dosing guidelines become available, clinicians will have to rely on the principles of drug dosing in critically ill and known PK alterations induced by ECMO itself. This article summarises the PK alterations and makes preliminary recommendations on possible dosing approaches.
This paper presents the findings of an outdoor thermal comfort study conducted in Hong Kong using longitudinal experiments--an alternative approach to conventional transverse surveys. In a longitudinal experiment, the thermal sensations of a relatively small number of subjects over different environmental conditions are followed and evaluated. This allows an exploration of the effects of changing climatic conditions on thermal sensation, and thus can provide information that is not possible to acquire through the conventional transverse survey. The paper addresses the effects of changing wind and solar radiation conditions on thermal sensation. It examines the use of predicted mean vote (PMV) in the outdoor context and illustrates the use of an alternative thermal index--physiological equivalent temperature (PET). The paper supports the conventional assumption that thermal neutrality corresponds to thermal comfort. Finally, predictive formulas for estimating outdoor thermal sensation are presented as functions of air temperature, wind speed, solar radiation intensity and absolute humidity. According to the formulas, for a person in light clothing sitting under shade on a typical summer day in Hong Kong where the air temperature is about 28°C and relative humidity about 80%, a wind speed of about 1.6 m/s is needed to achieve neutral thermal sensation.
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