Clinical Characteristics and Outcomes of Obstetric Patients Requiring Mechanical Ventilation in Colombia.

Clinical Characteristics and Outcomes of Obstetric Patients Requiring Mechanical Ventilation in Colombia.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 787A
Rojas-Suarez J, Dueñas C, Paternina A, Miranda J, Castillo E, Bourjeily G

SESSION TYPE: Physiology/PFTs/ Rehabilitation IPRESENTED ON: Sunday, October 21, 2012 at 01:15 PM – 02:45 PMPURPOSE: Respiratory failure requiring mechanical ventilation is an uncommon event during pregnancy. Physiologic changes of pregnancy and concerns for fetal wellbeing complicate the use of Mechanical Ventilation. The purpose of this study was to describe clinical characteristics of obstetric patients requiring Mechanical Ventilation, and their maternal and perinatal outcomes.METHODS: Observational retrospective study of all obstetric patients admitted to the Intensive Care Unit (ICU) at Rafael Calvo Maternity Hospital in Cartagena (Colombia), requiring Mechanical Ventilation for >24 hours between September, 2005 and December, 2011. Records were reviewed for demographic, diagnosis on admission and throughout stay, medical history, length of stay, perinatal and maternal mortality and ventilatory parameters.RESULTS: There were 750 ICU admissions during pregnancy or up to 6 weeks from the conclusion of pregnancy during the study period. A total of 131 (17.4 %) of patients required ventilatory support (32 during pregnancy), for a total of 822 ventilation days. The mortality rate was 23.6% (31 deaths) in Mechanical Ventilation patients. APACHE II was 8 (IQR 6-12) in non-ventilated patients and 14 (IQR 10-21) in ventilated patients (P<0.001). The median age was 24.3 years (SD±6.6). The median duration on mechanical ventilation was 3 days (IQR 1-6). Mean length of stay in ICU was 11.02 days (SD± 8.4). The most common diagnoses on admission were obstetric hemorrhage (36.2%) and gestational hypertensive disorders (29.8%). Volume-cycled was the most frequently used mode of ventilation (67/115 patients), with a mean tidal volume of 449.07mL (SD±90.7), and a mean Positive End-Expiratory Pressure (PEEP) of 7 cmH2O(SD± 2.4). Perinatal mortality (stillbirths and miscarriages) in ventilated mothers was 24.4%, and 15.4% in non-ventilated obstetric ICU patients (P<0.001).CONCLUSIONS: Maternal severity and perinatal mortality are significantly elevated in obstetric patients requiring mechanical ventilation.CLINICAL IMPLICATIONS: Given the elevated risk of mortality in obstetric patients requiring mechanical ventilation, aggressive therapeutic measures should be instituted.DISCLOSURE: The following authors have nothing to disclose: Jose Rojas-Suarez, Carmelo Dueñas, Angel Paternina, Jezid Miranda, Eliana Castillo, Ghada BourjeilyNo Product/Research Disclosure InformationUniversidad de Cartagena, Cartagena, Colombia. HubMed – rehab

A Rare Cause of Neurologic Devastation in the ICU.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 318A
Meehan P, Ezzie M

SESSION TYPE: Critical Care Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM – 02:30 PMINTRODUCTION: Undifferentiated neurologic dysfunction represents an opportunity to expand the differential diagnosis. This case illustrates the importance of considering intravascular large B-cell lymphoma (IVLBCL) in patients with undiagnosed neurologic complaints.CASE PRESENTATION: A 69 year old man presented to the emergency department with progressive lower extremity weakness and paresthesias. He was in good health three months prior when these symptoms began in his feet and ascended. He underwent evaluations at local hospitals that included imaging and two lumbar punctures. No etiology was determined, but he was treated with intravenous corticosteroids and initially had mild improvement in symptoms. He was sent to rehabilitation where his symptoms progressed with loss of bowel and bladder control and paraplegia. In the emergency department, his neurologic exam was significant for lower extremity paresis, areflexia, sensory deficits to the level of T6, and altered sensorium. His mental status worsened requiring transfer to the intensive care unit for mechanical ventilation. Repeat brain magnetic resonance imaging (MRI) demonstrated progressive, diffuse white matter signal abnormalities. Spine MRI did not demonstrate cord lesions. Electromyography demonstrated a mild sensory neuropathy without evidence for inflammatory demyelination. Cerebral spinal fluid was significant for protein of 100 mg/dL (15-45 mg/dL) and oligoclonal bands. Complete blood counts, liver function tests, and metabolic panels were all normal. The patient’s hospitalization was complicated by venous thromboembolism, prolonged mechanical ventilation with ventilator associated pneumonia, seizures, and worsening mental status. He was transitioned to comfort care and subsequently expired. Autopsy revealed IVLBCL in the brain, lungs, liver, adrenal glands, and bone marrow.DISCUSSION: IVLBCL is a rare, aggressive and often fatal form of diffuse large B-cell lymphoma. It is characterized by malignant growth in small vessels of extranodal organs. Older patients are affected and present with skin lesions, non-specific neurologic complaints, anemia, or dyspnea. The vague presentation makes diagnosis difficult, and without a high index of suspicion, patients are often diagnosed post-mortem. The few published case series have reported a variety of neurological findings including dementia, tremor, seizures, paresis, sensory deficits and altered sensorium. Diagnosis can be made by biopsy of the affected organ. Anthracycline agents and rituximab have been used for the treatment of IVLBCL with improved survival; however, central nervous involvement portends a worse prognosis.CONCLUSIONS: Unexplained neurologic symptoms should alert clinicians to consider IVLBCL as this is a rare but fatal illness, and recent treatment advances can improve survival.1) Shimada K, et.al. Presentation and management of intravascular large B-cell lymphoma. Lancet Oncol 2009; 10: 895-902.DISCLOSURE: The following authors have nothing to disclose: Patrick Meehan, Michael EzzieNo Product/Research Disclosure InformationThe Wexner Medical Center at The Ohio State University, Columbus, OH. HubMed – rehab

What is Better – Diffusion Capacity (DLCO) or DLCO Corrected for Alveolar Volume (DLCO/VA) – Relationship With Alveolar-Arterial Gradient.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 801A
Patolia S, Pokharel S, Gulati N, Vadde R, Perwaiz M, Narendra D, Patolia S, Schmidt F, Enriquez D, Quist J

SESSION TYPE: Physiology/PFTs/ Rehabilitation PostersPRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM – 02:30 PMPURPOSE: Diffusion across the blood-gas barrier is one of the parameter used to assess the lung function. There is no consensus about the use of DLCO or DLCO/VA to measure diffusion capacity of the lung. Alveolar-arterial gradient (A-a gradient) is an indirect measurement of diffusion. We conducted retrospective analysis to study the relationship of DLCO and DLCO/VA with the Alveolar-arterial gradient.METHODS: We retrospectively collected the data of pulmonary function test (PFT). Data were collected for the patients with acceptable arterial blood gas analysis (ABG). ? A-a gradient was calculated by subtracting calculated A-a gradient from expected A-a gradient for age. DLCO and DLCO/VA were graded as mild, moderate and severe if values were 61-80%, 41-60% and ? 40% of predicted respectively. ? A-a gradient was graded as 10-20, 20-30 and >30.RESULTS: 195 patients met the inclusion criteria. 98 (50.3%) of patients were female. Age range included 21-93 years with mean age of 57.45 years. Majority of the patients (79.5%) were African American. Mean % predicted DLCO (DLCO %) was 63.29 and mean % predicted DLCO/VA (DLCO/VA %) was 84.72. Mean ? A-a gradient was 14.05. 28 patients (14.4%) had DLCO higher than DLCO/VA and 163 (83.6%) had DLCO lower than DLCO/VA. Reduction in DLCO% was mild in 51, moderate in 46 and severe in 44 patients. Reduction in DLCO/VA% was mild in 41 patients, moderate in 29 patients, severe in 12 patients. ? A-a gradient was between 10 and 20 in 76 patients (39%), between 20 and 30 in 78 (40%) patients and more than 30 in 41 (21%) patients. For ? A-a gradient between 10-20- only 31.6% of patients with had normal DLCO as compared to 68.4% with normal DLCO/VA. Similarly for ? A-a gradient between 20-30- only 28.2% of patients had normal DLCO as compared to 60.3% patients with normal DLCO/VA. For ? A-a gradient of >30- only 19.5% of patients with had normal DLCO as compared to 34.1% with normal DLCO/VA. P values for Chi square test for all these results were <0.05.CONCLUSIONS: Our study shows that DLCO/VA has statistically significant higher false normal rate when A-a gradient is increased as compared to DLCO.CLINICAL IMPLICATIONS: Our study suggests that DLCO should be used preferentially for grading the severity of diffusion abnormalities.DISCLOSURE: The following authors have nothing to disclose: Setu Patolia, Saurav Pokharel, Neerja Gulati, Rakesh Vadde, Muhammad Perwaiz, Dharani Narendra, Swati Patolia, Frances Schmidt, Danilo Enriquez, Joseph QuistNo Product/Research Disclosure Information, Brooklyn, NY. HubMed – rehab