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It has become necessary to review septic shock in the light of recent experimental work, as well as the clinical implementation of this knowledge. Emphasis is laid on the surgical aspects of management of patients with this condition.
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It has been shown that apneic oxygenation can be safely performed for many days when metabolic carbon dioxide is removed by an extracorporeal membrane lung, and 100% oxygen is supplied directly into the trachea to keep the intrapulmonary pressure at 5 cm. H2O. The study was designed to find "best intrapulmonary pressure (IP)", analogous to "best PEEP" during continuous positive pressure ventilation. In the present study we have shown that when IP was progressively raised from 5cm H2O to 20 cm H2O the PaO2 rose significantly due to progressive decrease in QVA/Q. A linear positive correlation was found between CO and QVA/Q. There was a negative correlation between QVA/Q and FRC. Total static lung compliance and FRC increased significantly at 15--20 cm H2O IP. There was no significant change in urinary flow, urea and creatinine clearances. We conclude that in apneic oxygenation a more "optimal IP" is attained at an IP pressure of 20 cm H2O than at 5 cm H2O.
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Aspiration disease, a term used to define both an acute and chronic form of a disease entity, is described. Etiological factors, pathophysiology and therapy are discussed with emphasis on aspiration of gastric juice. A brief mention of a small clinical experience is included.
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We determined the incidence of pneumothorax in 295 infants (mean birthweight, 1,917 gm) with the respiratory distress syndrome (RDS) treated according to the same protocol. Fifty-five infants (mean birthweight, 1,594 gm) developed pneumothorax (incidence, 19%); incidence varied with severity of RDS and intensity of respiratory assistance. Pneumothorax occurred in 3.5% (2 of 58) of infants who received no assisted ventilation and in 11% (14 of 124) of infants who received continuous positive airway pressure (CPAP) as the only form of assisted ventilation; the difference between these two groups is not significant. Forty-nine infants initially treated with CPAP later required mechanical ventilation with positive end-expiratory pressure (PEEP). Pneumothorax occurred in 12 of the 49 (24%) and in 21 of 64 (33%) of those infants initially treated with PEEP; the incidence of pneumothorax for both these groups was significantly higher than for those treated with no assisted ventilation or CPAP only. To assess the value of frequent measurement of vital signs, blood gas tensions, and pH in the recognition of pneumothorax, we analyzed these variables by the cumulative sum statistical technique. We noted the following significant changes associated with pneumothorax: arterial blood pressure, heart rate, and respiratory rate decreased in 77% of cases; pulse pressure narrowed in 51% of cases; Po2 decreased in 17 of 20 cases in which ventilatory settings were constant for at least three hours prior to pneumothorax. However, pH and Pco2 showed consistent changes. Frequent measurements of vital signs and Po2 aid in the early diagnosis of pneumothorax.
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A new parachute cuff has been tested in combination with a positive end-expiratory pressure (PEEP) on mongrel dogs. During positive-pressure ventilation the intracuff and intratracheal pressures showed synchronous, identical pressure variations, and therefore theoretically with this type of cuff the pressure against the tracheal wall would be minimal. The cuff provided a seal against gas leakage from the lungs throughout the entire test period, i.e., for up to 7 h. To avoid aspiration of mouth contents during the passive exhalation phase, different amounts of PEEP were tested. A PEEP of 4.0--8.0 cm H2O always produced a seal against a column of fluid in the mouth exerting a hydrostatic pressure of 5.4--8.8 cm H2O against the cuff. This seal was maintained during the whole test period. No difference in sealing capacity was found when the cuff was used with a normal respiratory frequency (20/min) and with high-frequency positive-pressure ventilation (60/min). When the PEEP is eliminated, e.g., when the respirator is disconnected for suction of the endotracheal tube, the sealing effect will be abolished. As the cuff extends up into the larynx there will be no pooling of fluid above the cuff. The risk of aspiration can therefore be diminished by suction of oral cavity before disconnecting the respirator. With the use of the pneumatic valve principle together with high-frequency positive-pressure ventilation, an open respirator system can produce a continuous PEEP, thereby preventing aspiration even during suctioning of the tracheal tube.