Association Between Train-of-Four Values and Gas Exchange Indices in Moderate to Severe Acute Respiratory Distress Syndrome

Background: Acute respiratory distress syndrome (ARDS) is associated with a mortality rate of approximately 40%. Neuromuscular blockade is associated with an improvement in oxygenation and a reduction in mortality in ARDS. Objective: The goal of this evaluation was to determine if the depth of paralysis, determined by train-of-four (TOF) monitoring, correlates with gas exchange in moderate to severe ARDS. Methods: This was a retrospective review of moderate to severe ARDS patients who were prescribed >12 hours of continuous infusion cisatracurium between January 1, 2013, and December 31, 2014, with a PaO2:FiO2 ratio <150 and documented TOF and arterial blood gases. Patients were evaluated for inclusion at 12, 24, and 48 hours after initiation of neuromuscular blockade. Results: A total of 378 patients were screened for inclusion, with 107 evaluable patients meeting criteria at baseline. Poor correlation existed between TOF and oxygenation index (OI) at 12 (τ = 0.03), 24 (τ = 0.15) and 48 hours (τ = 0.08). When controlling for proning and baseline OI, the depth of paralysis did not have a significant effect on OI at 12, 24, or 48 hours. Conclusions: This evaluation demonstrates that the use of TOF monitoring for neuromuscular blockade does not correlate with gas exchange markers in moderate to severe ARDS.

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Effects of PDE3 Inhibitor Olprinone on the Respiratory Parameters, Inflammation, and Apoptosis in an Experimental Model of Acute Respiratory Distress Syndrome

International Journal of Molecular Sciences ◽

10.3390/ijms21093382 ◽

2020 ◽

Vol 21 (9) ◽

pp. 3382

Author(s):

Petra Kosutova ◽

Pavol Mikolka ◽

Sona Balentova ◽

Marian Adamkov ◽

Andrea Calkovska ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Arterial Oxygen Saturation ◽

Oxygenation Index ◽

Arterial Oxygen ◽

Arterial Blood ◽

Respiratory Parameters ◽

Pde3 Inhibitor

This study aimed to investigate whether a selective phosphodiesterase-3 (PDE3) inhibitor olprinone can positively influence the inflammation, apoptosis, and respiratory parameters in animals with acute respiratory distress syndrome (ARDS) model induced by repetitive saline lung lavage. Adult rabbits were divided into 3 groups: ARDS without therapy (ARDS), ARDS treated with olprinone i.v. (1 mg/kg; ARDS/PDE3), and healthy ventilated controls (Control), and were oxygen-ventilated for the following 4 h. Dynamic lung–thorax compliance (Cdyn), mean airway pressure (MAP), arterial oxygen saturation (SaO2), alveolar-arterial gradient (AAG), ratio between partial pressure of oxygen in arterial blood to a fraction of inspired oxygen (PaO2/FiO2), oxygenation index (OI), and ventilation efficiency index (VEI) were evaluated every hour. Post mortem, inflammatory and oxidative markers (interleukin (IL)-6, IL-1β, a receptor for advanced glycation end products (RAGE), IL-10, total antioxidant capacity (TAC), 3-nitrotyrosine (3NT), and malondialdehyde (MDA) and apoptosis (apoptotic index and caspase-3) were assessed in the lung tissue. Treatment with olprinone reduced the release of inflammatory mediators and markers of oxidative damage decreased apoptosis of epithelial cells and improved respiratory parameters. The results indicate a future potential of PDE3 inhibitors also in the therapy of ARDS.

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Milky Lungs: Ultrasonographic Findings in Pediatric Acute Respiratory Distress Syndrome

Central European Annals of Clinical Research ◽

10.35995/ceacr2010005 ◽

2020 ◽

Vol 2 (1) ◽

pp. 1

Author(s):

Naumovski Filip ◽

Toleska Marija ◽

Kuzmanovska Biljana ◽

Kartalov Andrijan ◽

Trposka Angela

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Gas Exchange ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Lung Ultrasound ◽

Surgical Intensive Care Unit ◽

Non Invasive ◽

Arterial Blood ◽

B Lines

Diagnosis and following up the dynamics of Pediatric Acute Respiratory Distress Syndrome demand a more feasible, non-invasive and bedside tool, such as lung ultrasound, for monitoring the damaged lungs. We report on a 6-month-old child admitted in our Pediatric Surgical Intensive Care Unit with a clinical presentation of ileus and concomitant community acquired pneumonia. Lung ultrasound (LUS) examinations according to the BLUE Protocol were done several times during the hospital stay. A-lines were seen at admission in the upper segments, but 2–3 B-lines were present in the posterolateral segments bilaterally. Later on, separated and coalescent B-lines were seen. White lung parenchyma or milky lungs with a thickened pleural line were seen, while the worst gas exchange according to the results of Arterial Blood Gases (ABGs) has been detected. According to the findings, as many B-lines will be detected, as the severeness of lung damage and gas exchange impairement. The improvement of the gas exchange with the disappearance of the coalescent B-lines was seen later on, after ventilating the child in a prone position. Bedsides, LUS is a feasible and non-invasive point of care method that could be used for diagnosing Pediatric Acute Respiratory Distress Syndrome (PARDS) but in guiding therapy of the damaged lungs, also. The finding of diffuse, coalescent and homogenous B-lines interpreted as “Milky lungs” is consistent with the diagnosis of PARDS.

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Cisatracurium Continuous Infusion versus No Neuromuscular Blockade for Acute Respiratory Distress Syndrome on Veno‐venous Extracorporeal Membrane Oxygenation

The Journal of Clinical Pharmacology ◽

10.1002/jcph.1933 ◽

2021 ◽

Author(s):

Christian Kressin ◽

Melissa Thompson Bastin ◽

Ayesha Ather ◽

Anil Gopinath ◽

Habib Srour ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Continuous Infusion ◽

Neuromuscular Blockade ◽

Distress Syndrome ◽

Membrane Oxygenation

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Comparison of fixed dose versus train-of-four titration of cisatracurium in acute respiratory distress syndrome

Journal of Critical Care ◽

10.1016/j.jcrc.2021.05.011 ◽

2021 ◽

Author(s):

Melissa L. Thompson Bastin ◽

Rebecca R. Smith ◽

Brittany D. Bissell ◽

Heather N. Wolf ◽

Alexandra M. Wiegand ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Fixed Dose ◽

Train Of Four

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Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study

Critical Care ◽

10.1186/s13054-021-03537-1 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Chiara Robba ◽

◽

Lorenzo Ball ◽

Denise Battaglini ◽

Danilo Cardim ◽

...

Keyword(s):

Carbon Dioxide ◽

Acute Respiratory Distress Syndrome ◽

Observational Study ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prospective Observational Study ◽

Distress Syndrome ◽

Cerebral Oxygenation ◽

Arterial Blood ◽

Early Effects

Abstract Background In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. Methods This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. Results Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57–69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51–54]% vs. 49 [47–50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56–71] to 82 [76–87] mmHg, p = 0.005) and rSO2 (from 53 [52–54]% to 60 [59–64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67–73] to 72 [67–73] mmHg, p = 0.015) and rSO2 (from 53 [51–56]% to 57 [55–59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75–79] to 64 [60–70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56–65]% vs. 56 [53–62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). Conclusions Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).

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Acute Kidney Injury in Pediatric Acute Respiratory Distress Syndrome

Journal of Intensive Care Medicine ◽

10.1177/0885066620944042 ◽

2020 ◽

pp. 088506662094404

Author(s):

Shubhi Kaushik ◽

Sindy Villacres ◽

Ruth Eisenberg ◽

Shivanand S. Medar

Keyword(s):

Acute Kidney Injury ◽

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Invasive Mechanical Ventilation ◽

Tertiary Care ◽

Kidney Injury ◽

Oxygenation Index ◽

Significant Difference

Objectives: To describe the incidence of and risk factors for acute kidney injury (AKI) in children with acute respiratory distress syndrome (ARDS) and study the effect of AKI on patient outcomes. Design: A single-center retrospective study. Setting: A tertiary care children’s hospital. Patients: All patients less than 18 years of age who received invasive mechanical ventilation (MV) and developed ARDS between July 2010 and July 2013 were included. Acute kidney injury was defined using p-RIFLE (risk, injury, failure, loss, and end-stage renal disease) criteria. Interventions: None. Measurements and Main Results: One hundred fifteen children met the criteria and were included in the study. Seventy-four children (74/115, 64%) developed AKI. The severity of AKI was risk in 34 (46%) of 74, injury in 19 (26%) of 74, and failure in 21 (28%) of 74. The presence of AKI was associated with lower Pao 2 to Fio 2 (P/F) ratio ( P = .007), need for inotropes ( P = .003), need for diuretics ( P = .004), higher oxygenation index ( P = .03), higher positive end-expiratory pressure (PEEP; P = .01), higher mean airway pressure ( P = .008), and higher Fio 2 requirement ( P = .03). Only PEEP and P/F ratios were significantly associated with AKI in the unadjusted logistic regression model. Patients with AKI had a significantly longer duration of hospital stay, although there was no significant difference in the intensive care unit stay, duration of MV, and mortality. Recovery of AKI occurred in 68% of the patients. A multivariable model including PEEP, P/F ratio, weight, need for inotropes, and need for diuretics had a better receiver operating characteristic (ROC) curve with an AUC of 0.75 compared to the ROC curves for PEEP only and P/F ratio only for the prediction of AKI. Conclusions: Patients with ARDS have high rates of AKI, and its presence is associated with increased morbidity and mortality.

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Faculty Opinions recommendation of Early neuromuscular blockade in the acute respiratory distress syndrome.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.735789046.793567302 ◽

2019 ◽

Author(s):

Kathryn Anne Hibbert

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Neuromuscular Blockade ◽

Distress Syndrome

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Neuromuscular Blockade Applicability in Early Acute Respiratory Distress Syndrome

Anesthesiology ◽

10.1097/aln.0000000000003180 ◽

2020 ◽

Vol 132 (6) ◽

pp. 1577-1584

Author(s):

William E. Hurford

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Neuromuscular Blockade ◽

Distress Syndrome ◽

Deep Sedation

Neuromuscular blockade with deep sedation appears to offer no advantage to patients with acute respiratory distress syndrome who can be managed with lighter sedation. In those patients requiring deep sedation, the addition of neuromuscular blockade may be beneficial.

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