Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: PATIENT PROFILES AND CLINICAL TECHNIQUES part 2

Case 2

One week following an acute myocardial infarction, a 37-year-old native American woman (Fig 2) required emergency replacement of the mitral valve for severe acute mitral regurgitation. The postoperative course was complicated by diffuse pulmonary infil­trates and prolonged ventilator dependence. By the seventh hospital day, there had been no improvement in the ARDS in spite of supportive measures. Hemodynamic measurements showed a wedge pressure of 19 mm Hg and pulmonary artery pressures of 43/29. A ^Ga citrate scan demonstrated significant pulmonary uptake of isotope at 48 hours (Fig 3). A rapidly tapering dose of ACS was given, and distinctive improvements in oxygenation and chest roentgenogram were observed. The patient was successfully weaned from mechanical ventilation and extubated. However, the patient, who had been improving daily, began to deteriorate without apparent reason.

FIGURE 2. Clinical course ofpatient

FIGURE 2. Clinical course of patient 2. Format the same as in Figure 1. The CPAP mask stands for a full face mask with positive pressure applied on a continuous basis. Inspired oxygen was augmented throughout the hospital stay except where indicated that room air was used.

FIGURE 3. Thoracic portion of

FIGURE 3. Thoracic portion of ^Ga citrate scan in patient 2 on the seventh day of ARDS. Measurements of pulmonary uptake were a computer derived ratio of 1.7 (pulmonary/background) and a visual score of 3 (maximum on 0-3 scale).

The progressive deterioration was consistent with ARDS. Repeat pulmonary arterial catheter measurements showed a pulmonary arterial pressure of 35/20 with a wedge pressure of 15. The cardiac output was 5.9 liters. A repeat етСа scan demonstrated further uptake of isotope. The ACS therapy was reinstituted although heated debate regarding its value and safety occurred. Again, a pattern of improvement was recorded. Fifteen days after the reinstitution of ACS, the patient was able to obtain satisfactory oxygenation from room air. The roentgenogram cleared and the ARDS was felt to be resolved. Unexpectedly, the patient had a sudden cardiac arrest the day prior to her planned discharge and died. A postmortem examination could not be performed. tadacip 20

FIGURE 4. Clinical course of patient 3

FIGURE 4. Clinical course of patient 3. Format similar to Figure 1 and 2.

FIGURE 5. Portable chest

FIGURE 5. Portable chest roentgenogram of patient 3 prior to onset of adrenocortical steroid therapy taken on the 25th hospital day.

Case 3

A 40-year-old native American woman (Fig 4) was admitted after an assault for treatment of multiple facial fractures and exposure. She was intubated upon admission for airway control but subse­quently developed pneumonia and later bilateral pulmonary infil­trates. When consulted on the 24th hospital day, an author found the patient to be ventilator-dependent with hypoxemic and hyper- carbic respiratory failure, noncompliant lungs, and diffuse roent­genographs abnormalities (Fig 5). ACS therapy was begun. Carbon dioxide retention improved rapidly, and over the ensuing 14 days, the patient showed marked improvement in oxygenation, compli­ance, and on roentgenogram (Fig 6). On the 14th day of therapy, she was weaned from mechanical ventilation, and by the 18th day after initiating ACS, she was satisfactorily oxygenated on room air. Cialis Jelly

FIGURE 6. Portable chest roentgenogram

FIGURE 6. Portable chest roentgenogram of patient 3 after 14 days of adrenocortical steroid therapy taken on the 39th hospital day.


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