Days Of Ventilatory Support Research Articles

Prospective Evaluation of 50 Consecutive Scoliosis Patients Surgically Treated With Thoracoscopic Anterior Instrumentation

Prospective, consecutive, single-surgeon case series of patients treated for scoliosis with thoracoscopic anterior spinal instrumentation. A thoracoscopic approach for insertion of anterior instrumentation has been developed in the past 10 years, which obviates many of the disadvantages of the open anterior thoracic approach. The morbidity associated with a thoracoscopy is limited because of the minimal skin and chest wall dissection required with this method. The purpose of this evaluation is to report a single surgeon's experience with an initial series of 50 patients. The goal is to report the outcomes with regards to the radiographic findings, pulmonary function, and the SRS Outcomes Instrument, as well as a review of the perioperative data and complications. The primary author's initial 50 thoracoscopic anterior spinal instrumentation patients were consecutively collected. Data collection included demographics, such as age, gender, and diagnosis. Data regarding the surgical procedure included the operative time, intraoperative estimated blood loss, as well as the number of levels instrumented anteriorly. In the perioperative hospital period, data were collected with regard to the length of the hospital stay, the number of days in the ICU, the number of days of ventilator support, and the number of days after surgery when conversion from IV to PO pain medication occurred. Radiographic data were obtained systematically on each patient and measured by authors other than the surgeon. The SRS 22 and/or 24 Outcomes Questionnaire and pulmonary function tests were administered to patients at similar intervals. The series consisted of 44 females and 6 males with a mean age of 14 years (range, 9-48 years). Forty-five of the 50 patients were available for clinical and radiographic evaluation at greater than or equal to 2 years after surgery. The average length of follow-up for these 45 patients was 33 months (range, 2-5 years). The mean operative time for the procedure was 350 +/- 50 minutes and ranged from 265 to 528 minutes. The estimated intraoperative blood loss averaged 431 +/- 273 mL (range, 75-1,400 mL). Normalizing the operative time and estimated blood loss based on the number of levels treated resulted in an average operative time per level of 48 +/- 6 minutes per level and an estimated intraoperative blood loss per level of 60 +/- 37 mL per level. The preoperative thoracic Cobb averaged 53 degrees +/- 9 degrees (range, 40 degrees-80 degrees). At most recent follow-up (> or = 2 years), the thoracic Cobb averaged 24 degrees +/- 7 degrees. Implant failure occurred in 3 cases. Thoracoscopic anterior instrumentation for adolescent idiopathic scoliosis is a viable surgical option. The outcomes of this consecutive series of patients is comparable to prior open and endoscopic series presented in the literature. The technical challenges of this operation are evident in the learning curve effect, which has been demonstrated.

Early tracheostomy versus late tracheostomy in the surgical intensive care unit

Background This study’s purpose was to determine if early tracheostomy (ET) of severely injured patients reduces days of ventilatory support, the frequency of ventilator-associated pneumonia (VAP), and surgical intensive care unit (SICU) length of stay (LOS). Methods This 2-year retrospective review included 185 SICU patients with acute injuries requiring mechanical ventilation and tracheostomy. ET was defined as 7 days or less, and late tracheostomy (LT) as more than 7 days. Results The incidence of VAP was significantly higher in the LT group, relative to the ET group (42.3% vs. 27.2%, respectively; P <.05). Acute Physiology and Chronic Health Evaluation II scores, hospital and SICU LOS, and the number of ventilator days were significantly higher in the LT group. Conclusions In patients who required prolonged mechanical ventilation, there was significant decreased incidence of VAP, less ventilator time, and lower ICU LOS when tracheostomy was performed within 7 days after admission to the SICU.

Rupture of a chronic expanding hematoma of the thorax into lung parenchyma

Rupture of a chronic expanding hematoma of the thorax into lung parenchyma

Ventilator-Associated Pneumonia Complicating the Acute Respiratory Distress Syndrome

Pulmonary infections span a wide spectrum, ranging from self-limited processes (e.g., tracheobronchitis) to life-threatening infections including both community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). Together, pneumonia and influenza rank as the sixth leading cause of death in the United States and lead all other infectious diseases in this respect. Pneumonia is the second-most-common hospital-acquired infection in the United States, accounting for 17.8% of all hospital-acquired infections and 40,000 to 70,000 deaths per year. HAP is the most common nosocomial infection occurring in patients requiring mechanical ventilation, developing in 6.5% of patients after 10 days and in 28% of patients after 30 days of ventilatory support. Patients acquiring HAP have a greater risk of mortality than comparably ill ventilated patients who do not develop pneumonia. Ventilator-associated pneumonia (VAP) specifically refers to a bacterial pneumonia developing in patients with acute respiratory failure who have been receiving mechanical ventilation for at least 48 hours. The etiologic bacteriologic agents associated with VAP typically differ based on the timing of the occurrence of the infection relative to the start of mechanical ventilation. VAP occurring within 96 hours of the onset of mechanical ventilation is usually due to antibiotic-sensitive bacteria that colonize the patient prior to hospital admission (e.g., Streptococcus pneumoniae, Haemophilus influenza, oxacillin-sensitive Staphylococcus aureus). VAP developing after 96 hours of ventilatory support is more often associated with antibiotic-resistant bacteria including oxacillin-resistant Staphylococcus aureus, Acinetobacter species and Pseudomonas aeruginosa. However, more recent data suggest that hospitalization and exposure to antibiotics prior to the start of mechanical ventilation are important risk factors for the occurrence of VAP attributed to antibiotic-resistant bacteria. Therefore, these risk factors should be considered when deciding on an appropriate empiric antibiotic regimen regardless of the onset of VAP. VAP and catheter-associated bloodstream infections are the leading causes of infection acquired in the intensive care unit (ICU) setting. Patients in the ICU have rates of HAP that are as much as five to ten times higher than the rates in general hospital wards. Additionally, like nosocomial bloodstream infections, VAP is associated with an attributable mortality beyond that accounted for by patients' severity of illness. The attributable mortality associated with VAP appears to be greatest for "high-risk'' antibiotic-resistant bacteria including Pseudomonas aeruginosa and oxacillin-resistant Staphylococcus aureus. The greater hospital mortality associated with these "high-risk'' pathogens has been attributed to the virulence of these bacteria and the increased occurrence of inadequate initial antibiotic treatment of VAP due to the presence of antibiotic resistance. This review provides an overview of the clinical importance of VAP. We then describe how this nosocomial infection influences the management and outcomes of patients with the acute respiratory distress syndrome (ARDS).

Severe Airflow Limitation After the Unifocalization Procedure

Background —While unifocalization techniques have improved the treatment options in patients with pulmonary atresia, ventricular septal defect (PA-VSD), and major aortopulmonary collaterals (MAPCAs), severe airflow limitation contributes to significant early postoperative morbidity and mortality. Although this has been attributed to bronchospasm, characteristically it is refractory to bronchodilators, suggesting that other mechanisms may play a role. Methods and Results —The clinical course and preoperative angiograms of patients who underwent unifocalization were reviewed. Patients who developed airflow limitation early after surgery underwent fiberoptic bronchoscopy. In addition, the anatomy of the MAPCAs was examined in 14 heart-lung blocks from patients with PA-VSD. Twenty-two procedures were performed in 16 children. Three developed marked airflow limitation early after surgery, necessitating prolonged high-pressure ventilation. Bronchoscopy demonstrated tracheobronchial epithelial necrosis in 2 and signs of tracheobronchial ischemia in the third. Two were successfully extubated after 15 and 16 days, but the third died after 57 days of ventilatory support. Review of the preoperative angiograms demonstrated an extensive peribronchial arterial supply arising from a MAPCA in 1 of the patients who developed severe airway necrosis after unifocalization. This was also obvious in a second patient, but the MAPCA was not included in the unifocalization. In 7 autopsy specimens, MAPCAs contributed to a peribronchial or peritracheal vascular network. Dissection of the distribution of these branches in 2 specimens revealed extensive intrapulmonary peribronchial anastomoses. Conclusions —Airflow limitation early after unifocalization is related to airway ischemia resulting from interruption of the tracheobronchial blood supply during mobilization of MAPCAs.

Severe Airflow Limitation After the Unifocalization Procedure : Clinical and Morphological Correlates

While unifocalization techniques have improved the treatment options in patients with pulmonary atresia, ventricular septal defect (PA-VSD), and major aortopulmonary collaterals (MAPCAs), severe airflow limitation contributes to significant early postoperative morbidity and mortality. Although this has been attributed to bronchospasm, characteristically it is refractory to bronchodilators, suggesting that other mechanisms may play a role. The clinical course and preoperative angiograms of patients who underwent unifocalization were reviewed. Patients who developed airflow limitation early after surgery underwent fiberoptic bronchoscopy. In addition, the anatomy of the MAPCAs was examined in 14 heart-lung blocks from patients with PA-VSD. Twenty-two procedures were performed in 16 children. Three developed marked airflow limitation early after surgery, necessitating prolonged high-pressure ventilation. Bronchoscopy demonstrated tracheobronchial epithelial necrosis in 2 and signs of tracheobronchial ischemia in the third. Two were successfully extubated after 15 and 16 days, but the third died after 57 days of ventilatory support. Review of the preoperative angiograms demonstrated an extensive peribronchial arterial supply arising from a MAPCA in 1 of the patients who developed severe airway necrosis after unifocalization. This was also obvious in a second patient, but the MAPCA was not included in the unifocalization. In 7 autopsy specimens, MAPCAs contributed to a peribronchial or peritracheal vascular network. Dissection of the distribution of these branches in 2 specimens revealed extensive intrapulmonary peribronchial anastomoses. Airflow limitation early after unifocalization is related to airway ischemia resulting from interruption of the tracheobronchial blood supply during mobilization of MAPCAs.

Impact of the fetal fibronectin assay on admissions for preterm labor

Objective: The aim of the study was to determine whether use of the fetal fibronectin assay would decrease the number of admissions to labor and delivery for diagnosis and treatment of preterm labor. Study Design: A prospective cohort design was used to compare preterm labor admissions during a 12-month period of fetal fibronectin assay use (study) against a baseline period before fetal fibronectin assay was implemented as standard protocol. Patients coming to the physician’s office or hospital with signs and symptoms of preterm labor had a sample obtained for fetal fibronectin assay per labeling criteria. Comparisons were made with the Mann-Whitney U test, independent Student t test, χ2 test, and Fisher exact test. P < .05 was considered significant. Results: There was no difference noted in the number of deliveries between the baseline and study years. During the study year 251 of 330 patients evaluated for preterm labor met study criteria and had the fetal fibronectin assay completed. Eight patients did not have fetal fibronectin assay results available because of specimen handling errors, leaving 243 subjects available for study. Compared with the baseline year, the study year had significantly fewer admissions for preterm labor, preterm labor admissions per patient, and prescriptions written for tocolytic agents. In addition, the length of stay per admitted patient was significantly reduced. The study population had no differences in neonatal outcomes from the baseline population in terms of deliveries at <35.0 weeks’ gestation, number of admissions to the neonatal intensive care unit, neonatal intensive care unit length of stay, or days of ventilatory support per patient admitted to the neonatal intensive care unit. Conclusions: Use of the fetal fibronectin assay resulted in significantly reduced preterm labor admissions, length of stay, and prescriptions for tocolytic agents. No negative impact on neonatal outcomes was observed. Reductions in admissions for preterm labor and in charges per admission resulted in approximately $486,000 saved during the study period. A trend toward increased corticosteroid administration (for neonates ultimately admitted to the neonatal intensive care unit) was noted. (Am J Obstet Gynecol 1999;180:581-6.)

Chronic Lung Disease (CLD) Significantly Increases the Utilization of Hospital Resources in Premature Infants 1216

Purpose: To evaluate the effect of chronic lung disease (CLD) on length of stay (LOS) and days of ventilator support (Vent days) in neonates discharged home from our neonatal intensive care unit. Setting: All neonates with a gestational age <34wks admitted to Crawford Long neonatal intensive (level III) care unit between July 1992 and August 1997. Methods: Data for all neonates admitted to our unit are prospectively entered into a computerized database. From this database, we compared the differences in average LOS and Vent days in neonates who developed CLD to those who did not. We excluded patients who were back transported to other institutions before discharge (n=79, 13% of admissions). CLD was defined as need for oxygen or ventilator support beyond 36 weeks post conception age. We used a Kruskal-Wallis ANOVA to compare differences in LOS and Vent days. Results: Of 534 neonates admitted, 489 (92%) survived and were discharged home. Fifty-seven (13%) of the 489 had CLD. Data on LOS and Vent days were missing on 15 patients, 2 with CLD and 13 without CLD. The average LOS and Vent days were significantly longer for neonates with CLD (see table, data listed as mean (std); *p<0.03 for all comparisons). Conclusions: The development of chronic lung disease in premature neonates has a marked effect on LOS and Vent days. These data emphasize the health care consequences of CLD in premature neonates.

Role of a short parenteral nutrition coupled with early enteral nutrition in the critically ill: a double-blind randomized study versus placebo

The critically ill, stressed, sometimes undernourished may develop an intestinal dysfunction which leads to multiple organ failure. Early enteral nutrition (EN) is usually recommended but may fail to provide an adequate amount of substrate. Parenteral nutrition (PN) is used in case of failure or contraindications of EN. However, the role of early EN coupled with PN has not been evaluated. We conducted a double-blind, randomized, placebo-controlled study to assess the influence of adjuvant PN (Vitrimix KV, Pharmacia Upjohn) and early EN on the improvement of nutritional parameters, morbidity and mortality in the critically ill, excepted after elective surgery. Statistical analysis, in intention to treat, used parametric tests (chi-2, ANOVA). Two groups of 60 patients (EN + placebo versus EN + PN) have been enrolled: 82 males, 38 females, admitted for medical (51%) or 33 non elective surgical emergencies (49%), SAPS2 (42 ± 14), who were either normonourished (59%), moderate (32%) or severe undernourished (9%). On follow-up from D0 to D4, we observed a significant improvement in nutritional proteins (transthyretine, RBP, transferrine) in the treated group, but not from D0 to D7. Mortality on D90 was identical in both groups (17 vs 18) as were the number of days of ventilatory support (11 vs 10), the cumulative number of nosocomial infections (29 vs 30), the length of stay in intensive care (16.9 vs 17.3), the OSF score measured on D0, D4, D7, D14 and D21 and the OMEGA score (263 vs 244). In contrast, we observed a significant reduction in the number of days of inotropic support (3.8 vs 4.4, P = 0.0001) and the length of hospital stay (31.2 vs 33.7, P = 0.0022). These results suggest that a short PN coupled with early EN is safe, synergistic and cost-effective. By immediately achieving a minimum energetic uptake, it may provide the time necessary for EN to restore intestinal function.

The effect of developmental care on preterm infant outcome

Using a retrospective comparative design, the investigators evaluated the effects of training 10% of a nursing staff in the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) on preterm infant outcomes. A convenience sample of 25 preterm infants (< 1500 grams) cared for during the NIDCAP implementation and training period were matched by birth weight and gestational age to infants born before NIDCAP implementation. Outcome measures collected through chart review showed NIDCAP infants had significantly fewer and less severe intraventricular hemorrhages, fewer days of ventilatory support, shorter hospitalizations, and greater rate of weight gain. Findings suggest that benefits of developmental care are achievable with only a portion of the staff being NIDCAP trained.

Correction of congenital diaphragmatic hernia in utero VII: A prospective trial

Background: Congenital diaphragmatic hernia (CDH) remains an unsolved problem. Despite optimal postnatal care, up to 60% of CDH babies die. Experimental evidence and clinical experience have shown that in utero repair of CDH is feasible and can reverse pulmonary hypoplasia, but only in fetuses without liver herniation. For this subgroup, the safety and efficacy of repair before birth has not been compared with standard care after birth. Methods: Four fetuses in whom CDH without liver herniation was diagnosed underwent open fetal surgery for repair of the CDH. Seven comparison fetuses were treated conventionally. Neonatal mortality was the principle outcome variable. Secondary outcome variables included death of all causes until 2 years of age, number of days of ventilatory support, length of hospital stay, requirement for extracorporeal membrane oxygenation (ECMO), and total hospital charges. Results: There was no difference in survival between the fetal surgery group and the postnatally treated comparison group (75% v 86%). Fetal surgery patients were born more prematurely than the comparison group (32 weeks v 38 weeks' gestation). Length of ventilatory support and requirement for ECMO were equivalent in the fetal surgery group and the postnatally treated comparison group. Length of hospital stay and hospital charges did not differ between the groups. Conclusions: Open fetal surgery is physiologically sound and technically feasible, but does not improve survival over standard postnatal treatment in the subgroup of CDH fetuses without liver herniation, primarily because overall survival in this subgroup is favorable with or without prenatal intervention. These data suggest that fetuses who have prenatally diagnosed CDH and without evidence of liver herniation should be treated postnatally.

Effect of passive stretching on the wasting of muscle in the critically ill

This study examine whether muscle wasting in critically ill patients can be prevented by passive stretching alone in the absence of contractile activity. Five critically ill patients who required a complete neuromuscular blockade for 7 days of ventilator support were studied. One leg of each patient was treated with continuous passive motion (CPM) for three 3-h periods daily while the other leg received only routine nursing care. Fiber atrophy was prevented in the more severely ill patients and there was a slight gain in fiber area (mean increase, +11%) in the CPM limb compared with the control leg, which decreased (mean decrease, -35%) over 7 days. Fiber area was preserved in both fiber types but was more pronounced in type I muscle fibers. Protein loss was significantly less in the CPM limb. There was a significantly greater increase in wet weight per mg DNA in the control limb. However, as an index of wasting, the ratio of protein to DNA decreased similarly in both limbs. Passive stretching can preserve the architecture of muscle fibers. Whether it can prevent muscle wasting remains uncertain.

Air embolism in the agitated traumatic brain injury patient: an unusual complication.

Central venous catheters are often utilized in the acute care management of the traumatic brain injury (TBI) patient. While in the agitated phase of recovery, TBI patients often focus on removing indwelling tubes or venous access lines. Air embolism is among the most serious complications reported in the use of central venous catheters. We present a case of air embolism in an agitated patient, and discuss prevention methodologies. A 38-year-old male was involved in a fall, with an initial Glasgow Coma Scale of 12. CAT scan imaging revealed a left frontal intracerebral haematoma. He required central venous catheter placement for management of associated chest and abdominal injuries. Agitated from early in his stay, the patient was able to twist off several hubs from the central venous catheter with his teeth, resulting in an air embolus. The patient experienced sudden clinical deterioration with oxygen saturation decling to 70%. The patient's course improved after several days of ventilatory support. He eventually successfully completed inpatient rehabilitation, achieving independence in activities of daily living and ambulation. This case illustrates a serious potential complication in the agitated patient. Physicians and rehabilitation specialists should advocate for secured taping of central venous catheter hubs and adequate padding of catheter dressings in agitated patients.

Pulmonary failure in geriatric patients with burns: the need for a diagnosis-related group modifier.

One hundred eleven patients with burns who were age 60 years or older were treated from January 1984 through December 1992. Twenty-nine patients had pulmonary failure defined as 7 or more days of ventilatory support from the day of burn. The mortality rate for these patients was 41%; only four were discharged to home. The mortality rate for patients without pulmonary failure was 11%. Billing information was analyzed for 102 of the 111 patients. Charges for patients without pulmonary failure were two to three times greater than reimbursement. Charges for patients with pulmonary failure were 4 to 14 times greater than reimbursement. Reimbursement for elderly patients with burns is inadequate. Altering the Diagnosis-Related Group (DRG) definition of extensive burn to reflect the severity of injury in the geriatric population is one step toward reimbursement reform. Patients who require 7 or more days of ventilatory support after burn injury should be reimbursed under a separate DRG category or should have a DRG modifier.

Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve

Median sternotomy is the most common approach for repeat cardiac surgery despite the potential complications of cardiac injury. Right anterolateral thoracotomy has been recommended as an alternative for patients undergoing mitral valve replacement, but data supporting one approach over the other do not exist, To compare these procedures, the records of 43 patients who had had a previous median sternotomy and who underwent mitral valve replacement were reviewed. No statistically significant differences between patients undergoing repeat median sternotomy (33 patients) and those undergoing right anterolateral thoracotomy (10 patients) were demonstrable when compared for age, gender, New York Heart Association Functional Class, other diseased valves, urgency of operation, indication for operation, type of valve removed, type of valve implanted, length of post operative hospitalization, length of operation, days of ventilatory support, length of intensive care unit stay, and survival (90% for thoracotomy group; 76% for median sternotomy group; p, NS). Significant differences between the two groups, favoring right anterolateral thoracotomy, were apparent when comparisons were made for length of perfusion (means, 94.8 min, thoracotomy group; 121.4 min, sternotomy group; p = .03), incidence of reexploration (0%, thoracotomy group; 13%, sternotomy group; p = .001), and blood transfusion (means, 5.3 units, thoracotomy group; 11.4 units, sternotomy group; p = .003). Right anterolateral thoracotomy is an effective alternative to repeat median sternotomy for replacement of the mitral valve in patients who have had a previous median sternotomy.

The effects of donor-recipient size disparity in infant and pediatric heart transplantation

To determine the effect of heart donor and recipient size mismatches in infant and pediatric heart transplantation, we studied all 69 patients (age 1 day to 11 years) having 71 orthotopic heart transplants from 1985 to 1989. Patients were divided into three groups based on donor to recipient weight ratios. Group I comprised 13 heart transplants with a donor to recipient weight ratio less than 0.95 (mean 0.81, range 0.48 to 0.94); group II comprised 29 heart transplants with a weight ratio between 0.95 and 1.60 (mean 1.28); and group III had 27 heart transplants with weight ratios greater than 1.60 (mean 2.2, range 1.61 to 3.09). All chests were closed primarily. The cardiothoracic ratio by chest radiography was significantly larger in group III (p = 0.0002); 75% of group III patients had periods of lobar or complete lung collapse by chest radiography compared with 28% of group II and 19% of group I patients (p < 0.05). Despite this, there was no difference in the number of days of ventilator support for any group (p = 0.92). There was no difference in graft ischemic time or inotropic drug use among groups, nor were differences found in the cardiac systolic function parameters of left ventricular preejection time (p = 0.975), left ventricular ejection time (p = 0.975), left ventricular fiber shortening (p = 0.97), and left ventricular fractional shortening (p = 0.596). Thus despite a high incidence of transient lobar or complete lung collapse in high donor to recipient weight ratio transplants, large donor heart size produces very little clinical impairment in recipient lung function. Size mismatches do not influence cardiac systolic function. Overall, large size mismatches appear to be very well tolerated in infant and pediatric heart transplantation.

Amiodarone-Induced Complications After Cardiac Operation for Obstructive Hypertrophic Cardiomyopathy

The occurrence of unanticipated and seemingly unexplicable major complications of hepatic, pulmonary, and cardiac dysfunction after palliative operation for obstructive hypertrophic cardiomyopathy prompted a review of 71 sequential patients. Fifty-five patients had been treated preoperatively with beta-blockers, calcium-channel inhibitors, or both, and 16 had received amiodarone for six to 566 days (mean time, 210 days) at total doses ranging from 8 to 175 g (mean dose, 82 g) and had drug-free intervals prior to operation of zero to 457 days (mean time, 91 days). Comparisons were made between the two treatment groups and between those with and without major complications within the amiodarone-treated group. Preoperative cardiac studies, sex, age, functional class, and type of operation were not related to outcome for the entire patient cohort. In amiodarone-treated patients, the major findings were as follows: a 50% incidence of hepatic dysfunction with a tenfold increase in concentrations of serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase; a 25% incidence of pulmonary dysfunction necessitating a fourfold increase in the number of days of ventilator support; and a 19% incidence of low cardiac output syndrome with two deaths. Only 44% of the amiodarone-treated group had no serious complications. The incidence of major complications of the liver, lungs, and heart was 2%, 0%, and 2%, respectively, in patients not treated with amiodarone. Abnormal preoperative pulmonary function studies were predictive of prolonged postoperative ventilatory support. Discontinuation of amiodarone for several months prior to operation appeared to reduce the incidence of major complications. The necessary drug-free interval required preoperatively could not be determined from this retrospective experience.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term respiratory support and risk of pneumonia in critically ill patients. Intensive Care Unit Group of Infection Control.

In 724 critically ill patients who had received prolonged (greater than 24 h) ventilatory assistance since admission to the ward, we analyzed the relationship between artificial ventilatory support and pulmonary infection. Two different approaches were used. The first, plotting the incidence of pneumonia versus the duration of ventilatory support, confirms previous data: the incidence rises from 5% in patients receiving one day of respiratory assistance to 68.8% in patients receiving more than 30 days. In the second approach, the same data were computed as an actuarial life table with the day of pneumonia onset as terminal event. This different approach, focusing on the onset of infection rather than on incidence, allows a new insight into the problem of nosocomial infection: pneumonia in patients with respiratory support is an early occurrence with a high and constant rate of acquisition and, therefore, a high risk of infection in the first eight to ten days. Later pneumonia acquisitions were rare, and the risk after ten days of ventilatory support is low.

Anterolateral Thoracotomy as an Alternative to Repeat Median Sternotomy for Replacement of the Mitral Valve

Median sternotomy is the most common approach for repeat cardiac surgery despite the potential complications of cardiac injury. Right anterolateral thoracotomy has been recommended as an alternative for patients undergoing mitral valve replacement, but data supporting one approach over the other do not exist. To compare these procedures, the records of 43 patients who had had a previous median sternotomy and who underwent mitral valve replacement were reviewed. No statistically significant differences between patients undergoing repeat median sternotomy (33 patients) and those undergoing right anterolateral thoracotomy (10 patients) were demonstrable when compared for age, gender, New York Heart Association Functional Class, other diseased valves, urgency of operation, indication for operation, type of valve removed, type of valve implanted, length of postoperative hospitalization, length of operation, days of ventilatory support, length of intensive care unit stay, and survival (90% for thoracotomy group; 76% for median sternotomy group; p, NS). Significant differences between the two groups, favoring right anterolateral thoracotomy, were apparent when comparisons were made for length of perfusion (means, 94.8 min, thoracotomy group; 121.4 min, sternotomy group; p = .03), incidence of reexploration (0%, thoracotomy group; 13%, sternotomy group; p = .001), and blood transfusion (means, 5.3 units, thoracotomy group; 11.4 units, sternotomy group; p = .003). Right anterolateral thoracotomy is an effective alternative to repeat median sternotomy for replacement of the mitral valve in patients who have had a previous median sternotomy.

Outcome and Function Following Prolonged Mechanical Ventilation

Prolonged periods of mechanically assisted ventilation are reasonably common occurrences, but there are no data regarding outcome for this patient population. We retrospectively reviewed the medical records of 250 consecutive patients with a minimum of ten days of ventilatory support during a five-year period. The overall survival was 39.2% at discharge, 28.6% at one year, and 22.5% at two years. Age and functional status prior to respiratory failure were the best predictors of survival. In addition, patients with postoperative or neurologic disease as the cause of respiratory failure were found to have the highest survival rate while those with cardiac and pulmonary disease had the worst prognosis. Of those patients who survived to discharge, 39.6% were institutionalized (nursing homes) and 32.7% were confined to their homes. Prolonged mechanical ventilation is associated with a limited survival and poor functional status in many who do survive.