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Ventricular Assistance as a Bridge to Cardiac Transplantation
Published in Wayne E. Richenbacher, Mechanical Circulatory Support, 2020
Patients with end stage heart failure have an excess of total body water. Intake is minimized by concentrating all intravenous infusions and eliminating maintenance intravenous fluids. As the systemic perfusion is determined by VAD flow there is no need for frequent cardiac output determinations. A thermodilution cardiac output may be obtained once or twice daily to ensure that it correlates with the VAD flow reported by the drive console. A continuous furosemide infusion ensures a forced diuresis during the first 24–48 hours following VAD implantation. One hundred milligrams of furosemide are mixed in 100 ml of 5% dextrose solution. The infusion is started at 10 ml/hour and increased while carefully monitoring intake and output. The goal is for total output to exceed intake by 1–2 liters over the first 24 hours. The furosemide infusion is titrated to achieve this endpoint. With aggressive diuresis the patient will develop a metabolic alkalosis. The metabolic alkalosis is corrected with acetazolamide sodium (250–500 mg IV q6h). Correction of the metabolic alkalosis permits early extubation. Thereafter, patients are instructed in the use of incentive spirometry. Respiratory treatments are employed if indicated. Chest physical therapy is gentle, if necessary, but rarely required.
The respiratory system
Published in Laurie K. McCorry, Martin M. Zdanowicz, Cynthia Y. Gonnella, Essentials of Human Physiology and Pathophysiology for Pharmacy and Allied Health, 2019
Laurie K. McCorry, Martin M. Zdanowicz, Cynthia Y. Gonnella
The amount of surfactant produced by alveolar type II cells decreases when breaths are small and constant. On the other hand, the amount of surfactant produced is increased in response to deep breaths due to stretching of the alveolar type II cells. Patients who have had thoracic or abdominal surgery often take small, shallow breaths because of the pain. The patients must be encouraged to regularly take deep breaths. To facilitate this, patients are often provided with an incentive spirometer. With a mouthpiece and a piston that rises during inspiration, the patient can visualize how deeply they are breathing.
The Pale Child
Published in Michael B O’Neill, Michelle Mary Mcevoy, Alf J Nicholson, Terence Stephenson, Stephanie Ryan, Diagnosing and Treating Common Problems in Paediatrics, 2017
Michael B O’Neill, Michelle Mary Mcevoy, Alf J Nicholson, Terence Stephenson, Stephanie Ryan
Acute painful episodes are the most frequent complication of sickle-cell disease. Obstruction of blood flow by sickled erythrocytes leads to hypoxia and acidosis and eventually to ischaemic injury. The presenting symptoms and signs are pain in the extremities with swelling, low-grade fever with associated redness and warmth. If it occurs in the abdomen there may be mild to severe pain. Patients who have experience of these episodes usually have taken paracetamol and codeine prior to presenting to the emergency department and require adequate analgesia – usually morphine intravenously with continuous infusion thereafter (for other options, seeEvidence 2). Discharge is possible once the pain has abated and the child is adequately hydrated. If inpatient treatment is required, (a) ensure adequate hydration (fluids, intravenous and oral) 1–1.5 times maintenance, (b) commence stool softeners while on narcotic medications, (c) use oxygen if hypoxaemia is present (oxygen saturation ≤94%), (d) use incentive spirometry for those able to co-operate (usually 5 years of age and older) -10 breaths every 1–2 hours while awake or five breaths every 15 minutes, (e) monitor pain (utilising an age-appropriate pain scale) and (f) ambulate as soon as is practical.
Acute chest syndrome of sickle cell disease: genetics, risk factors, prognosis, and management
Published in Expert Review of Hematology, 2022
Elizabeth S. Klings, Martin H. Steinberg
In the nearly total absence of controlled clinical trials, ACS management is guided by expert opinion that should be predicated on the risk for respiratory failure [44–47]. Howard and her associates provided 23 recommendations for management [48]. Especially noteworthy were the possible etiologic roles of volume overload that is typically due to diastolic dysfunction of the left ventricle and opioid-induced hypoventilation. Also noted were the poor prognosis associated with worsening hypoxia, thrombocytopenia and increasing anemia. A treatment pathway that included the use of higher levels of care such as the intensive care unit was beneficial. Little has changed since this and other reviews (Table 1). Incentive spirometry is recommended for all patients admitted to the hospital, especially those with ACS even though not all studies confirm its prophylactic efficacy [49,50]. Rib infarction, reported in up to 40% of ACS cases, can produce splinting with hypoventilation and atelectasis, hence the benefits of incentive spirometry [49,51]. Atelectasis may produce localized hypoxia in the setting of ventilation perfusion mismatch that can propagate the acute lung injury of ACS.
Evidence-based medicine: A data-driven approach to lean healthcare operations
Published in International Journal of Healthcare Management, 2021
We identified three recent literature reviews with meta-analyses conducted by the Cochrane Collaboration on the efficacy of incentive spirometer use in the postoperative period in the past seven years. Each of the reviews concluded that there is no evidence that incentive spirometry provides any benefit in reducing pulmonary complications after upper abdominal surgery or coronary artery bypass surgery [8–10]. Despite a lack of quality published evidence to support the use of incentive spirometry in the postoperative period, it continues to be standard practice to use IS in the perioperative period at nearly every medical center in the United States. It is unclear why widespread use of IS continues, but given the lack of data supporting its therapeutic benefits, it may represent significant financial waste and unnecessary work for nurses, respiratory technicians and patients.
Comparison of breathing patterns, pressure, volume, and flow characteristics of three breathing techniques to encourage lung inflation in healthy older people
Published in Physiotherapy Theory and Practice, 2019
Chulee Ubolsakka-Jones, Wiraporn Tasangkar, David A Jones
Incentive spirometry (IS) is routinely used in postoperative respiratory care, especially following upper abdominal and thoracic surgery, with the aim of preventing atelectasis, the most common pulmonary complication, but the value of IS has been questioned (Do Nascimento Junior et al., 2014; Freitas, Soares, Cardoso, and Atallah, 2012; Jenkins et al., 1989). Part of the problem may be that the breathing pattern or lung inflation achieved with some types of IS devices may not match the physiological requirements to properly inflate the lung and prevent atelectasis, specifically the need for deep, slow abdominal breathing. The ideal breathing pattern to achieve lung expansion is slow and deep inspiration, which allows airflow into the lower lung, and a hold for at least 3 s to increase collateral ventilation. The three breathing exercises examined here met these requirements to varying degrees (Table 3). Both DB and BM encourage slow and long inspiration, with BM being superior in this respect, probably due to the feedback provided by the bubbling sounds. However, while there was no problem with breath-hold during DB, subjects found it more difficult with BM and almost impossible with TF. Tidal volumes were significantly larger when using DB and BM compared with TF (Table 3), despite the much higher inspiratory flows (Figure 3A).