Effect of carbon dioxide pneumoperitoneum on bacteraemia and endotoxaemia in an animal model of peritonitis

The umbilicus is the site of a number of well-recognized and unusual congenital anomalies. The authors report two rare anomalies of the umbilicus, one involving the appendiceal artery and the other the appendix vermiformis.     

Transcutaneous measurement of partial pressure of oxygen and carbon dioxide

Transcutaneous monitoring is noninvasive and relatively simple to use. In neonates and small infants, this monitoring technique may provide very useful clinical information. Transcutaneous gas monitoring, using conventional electrochemical techniques, provides a means of trending the values of PaO2 and PaCO2 in most patients with relatively normal cardiovascular function. In patients with compromised cardiopulmonary function and in many adults, because of different skin structure, transcutaneous gas monitoring will not accurately reflect arterial blood gas tensions. Because transcutaneous gases depend on skin perfusion, however, it may be useful in monitoring tissue perfusion, especially in patients with peripheral vascular disease and tissue flaps. The heating of the monitoring probe necessitates frequent site changes to avoid thermal injury, which make it more labor intensive than other noninvasive monitoring methods.     

Effects of oxygen and carbon dioxide on mean cell volume

PURPOSE: Renal sonography is an accepted primary imaging modality for evaluating the pediatric urinary tract. We report a new sonographic finding associated with vesicoureteral reflux (VUR). METHODS: Ten patients underwent sonographic evaluation of the kidneys and were noted to have intermittent renal collecting system dilatation that expanded and contracted during real-time scanning. These patients were further evaluated with voiding cystourethrography. RESULTS: All 10 patients were proven to have VUR on the side of the sonographic abnormality. Four patients had bilateral VUR for a total of 14 refluxing renal units. Of these 14 renal units, 1 was sonographically normal. Five of the 14 renal units had grade V VUR that required surgical reimplantation of the ureter. CONCLUSIONS: This new finding of intermittent renal collecting system dilatation may become an important predictor of VUR. The finding warrants further evaluation even when detected in patients not suspected of having VUR who are undergoing renal sonography for other reasons.     

Expiratory flow limitation and intrinsic positive end-expiratory pressure in obesity

Breathing at very low lung volumes might be affected by decreased expiratory airflow and air trapping. Our purpose was to detect expiratory flow limitation (EFL) and, as a consequence, intrinsic positive end-expiratory pressure (PEEPi) in grossly obese subjects (OS). Eight OS with a mean body mass index (BMI) of 44 +/- 5 kg/m2 and six age-matched normal-weight control subjects (CS) were studied in different body positions. Negative expiratory pressure (NEP) was used to determine EFL. In contrast to CS, EFL was found in two of eight OS in the upright position and in seven of eight OS in the supine position. Dynamic PEEPi and mean transdiaphragmatic pressure (mean Pdi) were measured in all six CS and in six of eight OS. In OS, PEEPi increased from 0.14 +/- 0.06 (SD) kPa in the upright position to 0.41 +/- 0.11 kPa in the supine position (P < 0.05) and decreased to 0.20 +/- 0.08 kPa in the right lateral position (P < 0.05, compared with supine), whereas, in CS, PEEPi was significantly smaller (<0.05 kPa) in each position. In OS, mean Pdi in each position was significantly larger compared with CS. Mean Pdi increased from 1.02 +/- 0.32 kPa in the upright position to 1.26 +/- 0.17 kPa in the supine position (not significant) and decreased to 1. 06 +/- 0.26 kPa in the right lateral position (P < 0.05, compared with supine), whereas there were no significant changes in CS. We conclude that in OS 1) tidal breathing can be affected by EFL and PEEPi; 2) EFL and PEEPi are promoted by the supine posture; and 3) the increased diaphragmatic load in the supine position is, in part, related to PEEPi.     

Effects of positive end-expiratory pressure on right ventricular function in COPD patients during acute ventilatory failure

OBJECTIVE: To examine the effects of external positive end-expiratory pressure (PEEP) on right ventricular function in chronic obstructive pulmonary disease (COPD) patients with intrinsic PEEP (PEEPi). DESIGN: Prospective study. SETTING: General intensive care unit in a university teaching hospital. PATIENTS: Seven mechanically ventilated flow-limited COPD patients (PEEPi = 9.7 +/- 1.3 cmH2O, mean +/- SD) with acute respiratory failure. INTERVENTION: Hemodynamic and respiratory mechanic data were collected at four different levels of PEEP (0-5-10-15 cmH2O). MEASUREMENTS AND RESULTS: Hemodynamic parameters were obtained by a Swan-Ganz catheter with a fast response thermistor. Cardiac index (CI) and end-expiratory lung volume (EELV) reductions started simultaneously when the applied PEEP was approximately 90% of PEEPi measured on 0 cmH2O (ZEEP). Changes in transmural intrathoracic pressure (PEEPi,cw) started only at a PEEP value much higher (120%) than PEEPi. The reduction in CI was related to a decrease in the right end-diastolic ventricular volume index (RVEDVI) (r = 0.61; p < 0.001). No correlation between CI and transmural right atrial pressure was observed. The RVEDVI was inversely correlated with PEEP-induced changes in EELV (r = -55; p < 0.001), but no with PEEPi,cw (r = -0.08; NS). The relationship between RVEDVI and right ventricular stroke work index, considered an index of contractility, was significant in three patients, i.e., PEEP did not change contractility. In the other patients, an increase in contractility seemed to occur. CONCLUSIONS: In COPD patients an external PEEP exceeding 90% of PEEPi causes lung hyperinflation and reduces the CI due to a preload effect. The reduction in RVEDVI seems related to changes in EELV, rather than to changes in transmural pressures, suggesting a lung/heart volume interaction in the cardiac fossa. Thus, in COPD patients, application of an external PEEP level lower than PEEPi may affect right ventricular function.     

Exogenous surfactant and positive end-expiratory pressure in the treatment of endotoxin-induced lung injury

OBJECTIVE: To evaluate the efficacy of treating endotoxin-induced lung injury with single dose exogenous surfactant and positive end-expiratory pressure (PEEP). DESIGN: Prospective trial. SETTING: Laboratory at a university medical center. SUBJECTS: Nineteen certified healthy pigs, weighing 15 to 20 kg. INTERVENTIONS: Pigs were anesthetized and surgically prepared for hemodynamic and lung function measurements. Animals were randomized into four groups: a) Control pigs (n = 4) received an intravenous infusion of saline without Escherichia colilipopolysaccharide (LPS); b) the LPS group (n = 5) received an intravenous infusion of saline containing LPS (100 microg/kg); c) the PEEP plus saline group (n = 5) received an intravenous infusion of saline containing LPS. Two hours after LPS infusion, saline was instilled into the lung as a control for surfactant instillation, and the animals were placed on 7.5 cm H2O of PEEP; d) the PEEP plus surfactant group (n = 5) received an intravenous infusion of saline containing LPS. Two hours following LPS infusion, surfactant (50 mg/kg) was instilled into the lung and the animals were placed on 7.5 cm H2O of PEEP. PEEP was applied first and surfactant or saline was instilled into the lung while maintaining positive pressure ventilation. All groups were studied for 6 hrs after the start of LPS injection. At necropsy, bronchoalveolar lavage was performed and the right middle lung lobe was fixed for histologic analysis. MEASUREMENTS AND MAIN RESULTS: Compared with LPS without treatment, PEEP plus surfactant significantly increased PaO2 (PEEP plus surfactant = 156.6 +/- 18.6 [SEM] torr [20.8 +/- 2.5 kPa]; LPS = 79.2 +/- 21.9 torr [10.5 +/- 2.9 kPa]; p<.05), and decreased venous admixture (PEEP plus surfactant = 12.5 +/- 2.0%; LPS = 46.9 +/- 14.2%; p< .05) 5 hrs after LPS infusion. These changes were not significant 6 hrs after LPS infusion. PEEP plus surfactant did not alter ventilatory efficiency index (VEI = 3800/[peak airway pressure - PEEP] x respiratory rate x PacO2), or static compliance as compared with LPS without treatment at any time point. Cytologic analysis of bronchoalveolar lavage fluid showed that surfactant treatment significantly increased the percentage of alveolar neutrophils as compared with LPS without treatment (PEEP plus surfactant = 39.1 +/- 5.5%; LPS = 17.4 +/- 6.6%; p< .05). Histologic analysis showed that LPS caused edema accumulation around the airways and pulmonary vessels, and a significant increase in the number of sequestered leukocytes (LPS group = 3.4 +/- 0.2 cells/6400 micro2; control group = 1.3 +/- 0.1 cells/6400 micro2; p < .05). PEEP plus saline and PEEP plus surfactant significantly increased the total number of sequestered leukocytes in the pulmonary parenchyma (PEEP plus surfactant = 8.2 +/- 0.7 cells/6400 micro2; PEEP plus saline = 3.9 +/- 0.2 cells/6400 micro2; p <.05) compared with the control and LPS groups. CONCLUSIONS: We conclude that PEEP plus surfactant treatment of endotoxin-induced lung injury transiently improves oxygenation, but is unable to maintain this salutary effect indefinitely. Thus, repeat bolus dosing of surfactant or bolus treatment followed by continuous aerosol delivery may be necessary for a continuous beneficial effect.     

Effects of extrinsic positive end-expiratory pressure on mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation

OBJECTIVE: To examine the circulatory and respiratory effects of extrinsic positive end-expiratory pressure (PEEPe) in patients with chronic obstructive pulmonary disease (COPD) and dynamic hyperinflation during controlled mechanical ventilation. DESIGN: Different levels of PEEPe were applied randomly in mechanically ventilated patients with COPD and dynamic hyperinflation. SETTING: Respiratory Intensive Care Unit of a University Hospital. PATIENTS: 9 patients with acute respiratory failure and dynamic hyperinflation due to acute exacerbation of COPD. INTERVENTIONS: PEEPe 35%, 58% and 86% of intrinsic PEEP (PEEPi) were applied. MEASUREMENTS AND RESULTS: Using flow-directed pulmonary artery catheters hemodynamic measurements were obtained, while simultaneously lung volumes, airflows and airway pressures were recorded. In order to estimate alveolar pressures (Palv), rapid airway occlusions during passive expiration were also performed. At no level of PEEPe were significant changes in cardiac output, gas exchange variables, dead space, airways inflation resistances and respiratory system static end-inspiratory compliance observed. At high level of PEEPe central venous, mean pulmonary arterial and pulmonary capillary wedge pressures were increased significantly. All but one patient were flow-limited during passive expiration. PEEPe 86% of PEEPi caused a significant increase in end-expiratory lung volume and total PEEP. Iso-volume pressure-flow curves showed volume-dependence expiratory flow limitation in 2 patients, while in 8 patients volume-dependence of critical driving pressure (Palv-mouth pressure) that decreased flows was also observed. CONCLUSIONS: The effects of PEEPe on iso-volume flow and hence on lung mechanics and hemodynamics, depend on many factors, such as airways resistances, lung volumes and airway characteristics, making the patient response to PEEPe unpredictable.     

Effects of intraabdominally insufflated carbon dioxide and elevated intraabdominal pressure on splanchnic circulation: an experimental study in pigs

Scimitar-horned oryx sperm function was studied using protocols developed for domestic cattle. Objectives were to assess sperm 1) viability and motility in vitro over time, 2) capacitation in heparin- or calcium-supplemented medium, and 3) function in an in vitro fertilization system using heterologous (domestic cow) oocytes. Seminal aliquots were washed, and sperm were resuspended in 1) Talp with 5% fetal calf serum (TALP), 2) TALP + 10 microM heparin, 3) TALP + 20 microM heparin, and 4) TALP + 10 mM CaCl. At 0, 3, and 6 h, aliquots were evaluated for sperm motility, viability (using Hoechst 33258), and ability to acrosome-react when exposed to lysophosphatidylcholine (LC). Sperm function was assessed by evaluating fertilization and embryo development after coculture of in vitro-matured domestic cow oocytes with oryx sperm. Overall mean percentages of motile and viable sperm remained high at 6 h (> 60% and > 70%, respectively). Fewer (p < 0.05) sperm incubated in TALP + 10 microM heparin for 6 h contained intact acrosomes after exposure to LC, but there were no differences between LC and control samples after incubation in TALP without heparin. LC-treated sperm in TALP + 10 mM CaCl contained fewer (p < 0.05) intact acrosomes at 3 and 6 h (52.6% and 31.2%, respectively) than paired controls (83.6% and 70.0%, respectively). Oryx sperm from all males were capable of fertilizing cow oocytes (range 17 of 26 [65.4%] to 25 of 26 [96.2%]). Of the 55 2-cell embryos produced, 34 (61.8%) developed to > or = 8 cells. Of the 24 uncleaved oocytes, 7 (29.2%) were polyspermic. These data demonstrate that processed sperm from the endangered scimitar-horned oryx remain vigorous in vitro for at least 6 h. Capacitation can be induced using cattle sperm-processing techniques, with sperm appearing most responsive to elevated CaCl concentrations. Most interesting was the successful production and development of hybrid embryos after coincubation of oryx sperm with cow oocytes, suggesting that the two bovid species have similar fertilization mechanisms.     

Clinical examination reliably detects intrinsic positive end-expiratory pressure in critically ill, mechanically ventilated patients

Critically ill patients requiring mechanical ventilation often develop intrinsic positive end-expiratory pressure (PEEPi). Methods for its detection include an expiratory flow waveform display (not always available), an esophageal pressure transducer (invasive), or a relaxed or paralyzed patient. We sought to determine the accuracy of clinical examination for detecting PEEPi. Examiners blinded to waveform analysis assessed patients for the presence of PEEPi by inspection/palpation and auscultation. If either inspection/palpation or auscultation demonstrated PEEPi, it was said to be present by clinical exam. Clinicians with various levels of experience (attending, resident, student) made 503 observations of 71 patients. Sensitivity (SENS), specificity (SPEC), positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios were determined for inspection/palpation, auscultation, and clinical exam. PEEPi was present during 69.8% of observations. SENS, SPEC, and PPV of clinical exam were 0.72, 0.91, and 0.95 respectively for the examiners as a whole. Likelihood ratio for PEEPi detection by clinical exam was 8.35. Attending intensivists displayed SPEC and PPV of 1.0. NPV was only 0.58 (likelihood ratio 0.31). We conclude that the clinical exam is very good for detecting PEEPi at all experience levels; and further, that the clinical exam is only modestly useful for ruling out PEEPi, therefore, other tests should be used if PEEPi is not detected by clinical exam.     

Oxidation of aluminum-magnesium melts in air,oxygen, flue gas,and carbon dioxide

Oxidation rates of aluminum—1 to 14 pct magnesium melts in air, oxygen, flue gas, and carbon dioxide at temperatures from 600 to 1100°C were measured with an automatic recording balance. For most conditions, a protective amorphous film on the melt surface kept the oxidation rate low initially. After an interval that was shortened by increasing temperature or magnesium content, the film crystallized to magnesium oxide and magnesium aluminate, accompanied by a sudden increase in oxidation rate. Known as breakaway oxidation, this phenomenon could be produced by adding crystalline magnesium oxide or magnesium aluminate seed to melts protected with amorphous oxide. Flue gas or carbon dioxide in the atmosphere, sodium or beryllium in the alloy, or boron dusted on the surface delayed crystallization unless seed was added. Beryllium was the most effective. Flue gas from burning natural gas delayed breakaway oxidation of unseeded melts containing up to about 4 pct magnesium at normal melting furnace temperatures near 750°C. Slow melting of solid aluminum-magnesium alloy concentrated magnesium in the first liquid to melt, sharply decreasing the interval before breakaway oxidation after melting. Rapidly melting the solid increased the protective interval. Homogenizing the solid just below the melting range before rapid melting further extended the interval before the onset of breakaway oxidation.     

Increases in middle ear pressure resulting from counter-diffusion of oxygen and carbon dioxide into the middle ear of monkeys

Bryodin 1 (BD1) is a potent ribosome-inactivating protein (RIP) isolated from the plant Bryonia dioica. It is relatively nontoxic in rodents (LD50 > 40 mg/kg) and represents a potential improvement over other RIPs and bacterial toxins that have been used in immunotoxins. Recombinant BD1, expressed in Escherichia coli, localizes to insoluble inclusion bodies necessitating denaturation and refolding steps to generate active protein. In this report, BD1 was expressed as a soluble recombinant protein in tobacco cell culture (ntBD1) and purified to near homogeneity with yields of up to 30 mg/(L of culture). The protein synthesis inhibition activity of ntBD1 was identical to that of both native BD1 isolated from the roots of B. dioica and recombinant BD1 expressed in E. coli. Toxicology analysis showed that ntBD1 was well tolerated in rats at doses that cannot be achieved with most other toxin components of immunotoxins. Additionally, a single-chain immunotoxin composed of BD1 fused to the single-chain Fv region of the anti-CD40 antibody G28-5 (ntBD1-G28-5 sFv) was expressed in tobacco tissue culture as a soluble protein and was specifically cytotoxic toward CD40 expressing non-Hodgkin's lymphoma cells in vitro. These data indicate that tobacco tissue culture is a viable system for soluble expression of BD1 and BD1-containing immunotoxins.     

Computer analysis system of blood oxygen saturation in an animal hypoxia model

Forearm blood flow (ml/min/100 ml) was determined with strain-gauge venous occlusion plethysmography at rest and in response to handgrip exercise in 7 patients with congestive heart failure and in 9 normal subjects before and after regional administration of endothelin-1 in the brachial artery. Administration of endothelin-1 significantly decreased forearm blood flow at rest and during exercise in normal subjects but did not change it at rest or during exercise in patients with congestive heart failure.     

Small airway closure and positive end-expiratory pressure in mechanically ventilated patients with chronic obstructive pulmonary disease

The effects of positive end-expiratory pressure (PEEP) on alveolar recruitment and closing volume were studied in ten supine, sedated, and paralyzed patients with chronic obstructive respiratory disease and acute respiratory failure. We applied PEEP (0, 5, 10, and 15 cm H2O) and constructed inflation static volume-pressure (V-P) curves. In all patients, the static V-P curves obtained at different PEEP levels were superimposed on each other, indicating that with PEEP there was no recruitment of previously atelectatic lung units. However, the static V-P curves exhibited an inflection point, which should reflect the critical pressure (Po) required to reopen all closed airways, whilst the corresponding lung volume (Vo) reflects the opening volume. On average, Vo was 0.71 L above the relaxation volume of the respiratory system (Vr). All patients, however, exhibited dynamic hyperinflation, i.e., with zero PEEP (ZEEP) the end-expiratory lung volume (EELV) was 0.54 L above Vr. Nevertheless, in seven patients the EELV on ZEEP was below Vo, resulting in cyclic reopening and closure of small airways with each breathing cycle, with concomitant mechanical stresses on the peripheral airways that may lead to low-volume barotrauma. Such barotrauma may be prevented by increasing with PEEP the EELV to Vo.     

Local regulation of collateral ventilation by oxygen and carbon dioxide

The effects of changes in CO2 and O2 on the mechanics of collateral ventilation were studied in anesthetized paralyzed dogs. A doublelumen catheter was wedged into a peripheral airway obstructing a segment of lung distal to the catheter. Through one lumen of the catheter, air, 5% CO2 in air, 10% CO2 in air, 5% O2 in N2, or 5% CO2 in N2 was infused at a constant flow (V). Pressure (Ps) was monitored through the other lumen. At functional residual capacity the resistance to collateral flor Rcoll = Ps/V. When V was interrrupted , the time for Ps to fall 63% was defined as the time constant for collateral ventilation, Tcoll. The effective compliance (Cs') = Tcoll/Rcoll. When air was replaced by 5% CO2, Rcoll fell 46.3% (+/- SE 2.8) and Tcoll fell 41.5% (+/- SE 3.0). When the CO2 concentration was increased from 5% to 10%, Rcoll fell an additional 9.2% (+/- SE 2.2) and Tcoll fell an additional 5.1% (+/- SE 4.4). When air was replaced by 5% O2 in N2, Rcoll rose 36.6% (+/- SE 6.0) and Tcoll rose 13.6% (+/- SE 10.5). No significant changes in Cs' were noted. We conclude that varying concentrations of CO2 and O2 provide potent mechanisms for the control of collateral ventillation which may be of importance in the regulation of ventillation perfusion relationships at the local level.     

Influence of positive end-expiratory pressure ventilation (PEEP) on left ventricular pattern of contraction in experimental ARDS

The aim of the present study was to investigate the pattern of ventricular dynamic contraction and its relation to changes of transseptal pressure gradient during ventilation with positive end-expiratory pressure (PEEP). For that purpose, left (LV) and right ventricular (RV) pressures as well as ventricular shortening in septal-lateral (s.l.) direction were assessed in 8 dogs (RV n = 5) exposed to experimental acute respiratory distress syndrome (eARDS) and PEEP 10 and 20 cmH2O (P10, P20). Despite maintenance of transmural central venous pressure by volume substitution, PEEP resulted in a fall of stroke index (P10 vs. eARDS: -7%, p<0.05; P20 vs. P10: -28%, p<0.05); this was accompanied by a fall of LV end-diastolic diameter (P10 vs. eARDS: -3.1%, p<0.01; P20 vs. P10: -7.4%, p<0.01). Although the transseptal LV to RV end- diastolic pressure gradient changed only minimally, there was a significant increase of paradoxic left ventricular systolic lengthening from 3.1% at eARDS to 4.5% at P10 (p<0.05 vs. eARDS) and 8.4% at P20 (p<0.05 vs. P10). Neither RV end-diastolic diameter nor s.l. shortening were significantly influenced by P10 or P20. It is concluded, that a rearrangement of LV dynamic contraction does occur during ventilation with PEEP, which is compatible with the concept of paradoxic systolic bulging of the interventricular septum towards the lumen of the right ventricle. Since this phenomenon occurred independent from changes of the end-diastolic pressure gradient between both ventricles, we suggest that systolic septal movement to the right is an active contractile process to support the function of a stressed RV.     

Changes in oxygen saturation and transcutaneous carbon dioxide and oxygen levels in patients undergoing fibreoptic bronchoscopy

Though women have a lower absolute risk of disease than men at all ages, almost all the risk factors for cardiovascular disease carry the same or higher relative risk for women as for men. Moreover, the attributable risk is higher in older women than in men. Epidemiologic studies show that recent decreases in coronary heart disease mortality are in some cases greater among women than men. Interventional studies show that women appear to have as good or better a response than men to cholesterol-lowering in secondary prevention. Antihypertensive drug therapy is effective in preventing clinical endpoints in elderly women. These observations imply that an overall estimation of cardiovascular risk in women needs careful consideration. Because established therapies appear to be effective in high risk women, postmenopausal and probably also elderly women are important target groups for preventive efforts. The value of prevention for premenopausal women should not be underestimated, but should on the whole be approached through population-based strategies.     

Neither dopamine nor dobutamine corrects mesenteric blood flow depression caused by positive end-expiratory pressure in a rat model of acute lung injury

OBJECTIVE: To determine if either dopamine or dobutamine would counteract the deleterious effect that positive end-expiratory pressure (PEEP) has on cardiac output and mesenteric blood flow in a rat model of acute lung injury. DESIGN: Prospective, randomized, controlled trial in a clinically relevant model of acute lung injury. SETTING: Microcirculation research laboratory. SUBJECTS: Male Sprague-Dawley rats. INTERVENTIONS: The animals were anesthetized with pentobarbital (30 mg/kg) by intraperitoneal injection. They underwent tracheostomy, jugular and femoral vein cannulation, femoral artery cannulation, carotid artery thermistor placement, and bowel preparation for in vivo video microscopy. Acute lung injury was created by administering 0.1 N hydrochloric acid (1 mL/kg) via the tracheostomy. Dopamine or dobutamine (2.5 or 12.5 microg/kg/min), followed by two intravenous fluid boluses, was administered to rats ventilated with 5, 10, 15, and 20 cm H2O of PEEP. MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure, thermodilution cardiac output, mesenteric arteriolar diameter, and red blood cell velocity were measured and mesenteric blood flow was calculated. Cardiac output was depressed in rats exposed to 20 cm H2O of PEEP by 32+/-2%. The corresponding values for cardiac output depression at 20 cm H2O of PEEP in rats receiving 2.5 and 12.5 microg/kg/min of dopamine and 2.5 and 12.5 microg/kg/min of dobutamine were 31+/-1%, 21+/-1%, 29+/-0%, and 24+/-2%, respectively. Mesenteric blood flow was depressed in rats ventilated with 20 cm H2O of PEEP by 74+/-3%, while the corresponding values in rats exposed to 20 cm H2O of PEEP and receiving 2.5 or 12.5 microg/kg/min of dopamine or 2.5 or 12.5 microg/kg/min of dobutamine were 86+/-3%, 77+/-3%, 73+/-3%, and 66+/-3%, respectively. Fluid boluses did not correct the deficits in cardiac output or mesenteric blood flow caused by the combination of acute lung injury and PEEP. CONCLUSIONS: The higher doses of dopamine and dobutamine partially, but insignificantly, corrected the cardiac output depression caused by PEEP in a model of acute lung injury. Neither dose of dopamine nor dobutamine was able to improve PEEP-induced mesenteric blood flow depression.     

On the possible role of positive end-expiratory pressure ventilation in the treatment of chylothorax caused by blunt chest trauma

Recent reports on the treatment of chylothorax postulate a benefit to ventilator therapy, especially using positive end-expiratory pressure (PEEP). This report describes the use of mechanical ventilation with PEEP in the management of a 24-year-old male motorcyclist who sustained a ligamentous Chance fracture of the thoracic spine at the T6-7 level with bilateral traumatic chylothorax. Treatment of the chylothorax consisted of high PEEP ventilation, bilateral chest tube thoracostomies, and total parenteral nutrition. The chylothoraces resolved within 4 days of treatment and mechanical ventilation was stopped. Ventilator therapy of traumatic chylothorax and the physiologic grounds for its use are discussed. A review of the literature and experimental evidence seem to suggest that ventilator treatment of traumatic chylothoraces is effective.