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Biomedical subjects

P Squara

Publications and source records attributed to P Squara.

At least 19 recordsLinked to original sources
PubMed2005

[Prevention of venous thromboembolism following cardiac, vascular or thoracic surgery].

In the absence of thromboprophylaxis, coronary artery bypass graft surgery (CABG), intrathoracic surgery (thoracotomy or video-assisted thoracoscopy), abdominal aortic surgery and infrainguinal vascular surgery are high-risk surgeries for the development of venous thromboembolic events (VTE). The incidence of VTE following surgery of the intrathoracic aorta, carotid endarterectomy or mediastinoscopy is unknown. Data from the litterature are lacking to draw evidence-based recommandations for venous thromboprophylaxis after these three types of surgeries, and the following guidelines are but experts'opinions (Grade D recommendations). Thromboprophylaxis is recommended after CABG (Grade D), with either subcutaneous (SC) low molecular weight heparin (LMWH) or SC or intravenous (i.v.) unfractioned heparin (UH) (PTT target = 1.1-1.5 time control value) (both grade D). This may be combined with the use of intermittent pneumatic compression device (Grade B). After valve surgery. The anticoagulation recommended to prevent valve thrombosis is sufficient in order to prevent VTE. We recommend thromboprophylaxis with either LMWH or low dose UH to prevent VTE after aortic or lower limbs infrainguinal vascular surgery (both grade B and D). Vitamine K antagonists (VKA) are not recommended in this indication (Grade D). We recommend thromprophylaxis following intrathoracic surgery via thoracotomy or videoassisted thoracoscopy (grade C). Either subcutaneous LMWH or subcutaneous or i.v. low dose UH may be used (Grade C). Efficacy of intermittent pneumatic compression device has been demonstrated in a study (grade C). VKA are not recommended (grade D). No further recommendation regarding the duration of thromboprophylaxis after these three types of surgeries can be made.

Anesthesia↗
PubMed1998

Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study.

OBJECTIVE: Although the acute respiratory distress syndrome (ARDS) was identified as long as 30 years ago, potential therapeutic objectives have been defined from small series rather than large trials. Moreover, relationships between ARDS and hemodynamics are unclear. The European Collaborative ARDS Study was designed to identify factors influencing the pathogenesis, severity, and prognosis of ARDS. Analysis of the hemodynamic profiles collected during this study and of their contribution to the above-mentioned facets of ARDS is the focus of the present report. DESIGN: Prospective clinical study. SETTING: 38 European intensive care units (ICUs). PATIENTS AND METHODS: We collected 2758 sets of data from 586 patients, including baseline data, data on proven or suspected causes of ARDS differentiating direct and nondirect lung injury, and data on baseline status including multiple organ dysfunction (MOD) with differentiation of primary ARDS from ARDS secondary to severe systemic disorders. Events during follow-up were also recorded, including whether the acute respiratory failure did or did not improve after 24 h (groups A and B, respectively). When available, hemodynamic data were recorded at enrollment (day 0), on days 1-3, 7, 14, and 21, and at discharge or at the time of death in the ICU. RESULTS: Although the rate of pre-existing disease and the nature and rate of complications varied widely among etiologic categories, differences in the hemodynamic profile occurred only between primary and secondary ARDS. Both at inclusion and during the course of the illness, variables that were used to investigate Va/Q mismatch [arterial oxygen tension (PaO2, arterial oxygen saturation, right-to-left shunt, and the PaO2/fractional inspired oxygen (FIO2) ratio] predicted survival. High pulmonary artery pressure (PAP) and low systemic artery pressure (SAP) were also related to the prognosis. In the logistic regression model including hemodynamic and oxygen-related variables, however, the only independent predictors of survival were the ratio of right over left ventricular stroke work (RVSW/LVSW) and the PaO2/FIO2 ratio at admission. On day 2, the best prognostic model included: age [odds ratio (OR) = 1.04, p = 0.0004], opportunistic pneumonia as the cause of ARDS (OR = 3.2, p = 0.03), existence of MOD (OR = 1.9, p = 0.03), PaO2/FIO2 (OR = 0.96, p = 0.005), and RVSW/LVSW (OR = 25, p = 0.02). A high RVSW/LVSW ratio, high systolic PAP, low diastolic SAP, and low PaO2/FIO2, and increased right atrial pressure were negative prognostic indicators during follow-up. CONCLUSION: In addition to the cause of ARDS and the early time-course of lung function, a high systolic PAP and a low diastolic SAP were strong independent indicators of survival.

Adult↗
PubMed1997

Elastic energy as an index of right ventricular filling.

BACKGROUND: Right ventricle (RV) preload assessment remains controversial because the complexity of RV geometry is an obstacle to wall stress modeling. We developed a method to evaluate end-diastolic RV elastic energy (EL), a variable that integrates all the stretching effects of venous return and that can be easily estimated at the bedside from the area under the diastolic RV pressure-volume curve. The purpose of this study was to compare the clinical utility of EL and of the two conventional variables used to assess RV filling, ie, right atrial pressure (Pra) and RV end-diastolic volume (EDV). METHOD: We studied 26 postoperative patients who required a rapid fluid challenge. Energetics were evaluated by constructing the RV pressure-volume loop at the bedside using right heart catheterization with RV ejection fraction (EF) derivation. Correlations between RV filling and RV performance (ejection and mechanical efficiency) were studied. RV filling indexes were Pra, EDV, and EL. Indexes of RV ejection were stroke volume (SV), RV stroke work (RVSW), mechanical energy expenditure during ejection (EM), and total energy expenditure of contraction (ET). Indexes of RV mechanical efficiency were EF and the EM/ET ratio. RESULTS: Three important results were obtained. First, among RV ejection indexes, those that correlated best with RV filling indexes were EM and ET. Second, we found significant linear relationships between improved RV filling, as assessed by changes in EDV and EL, and improved RV ejection, as assessed by changes in SV, RVSW, EM, or ET. Third, changes in EDV and EL also predicted improved mechanical efficiency, as assessed by changes in EF and EM/ET. In, all situations, changes in EL yielded the strongest correlations. CONCLUSIONS: Derivation of EL is simple and appears to be the best clinical means of assessing Starling's law of the heart for the RV.

Adult↗
PubMed1996

Testicular neoplasm presenting as a major pulmonary embolism.

OBJECTIVE: To report an unusual and life-threatening presentation of a nonseminomatous germ cell tumor of the testis. METHODS: A 35-year-old male presented with pulmonary embolism secondary to a neoplastic thrombus from a nonseminomatous germ cell tumor. Prompt management involved surgical thrombectomy with cardiopulmonary bypass and deep hypothermic circulatory arrest, followed by orchiectomy and adjuvant chemotherapy. RESULTS: Three years later, the patient remains disease free according to physical examination, radiographic workup and serum markers. CONCLUSION: The excellent long-term outcome of this patient supports an aggressive multidisciplinary management of nonseminomatous germ cell tumors in young adults.

Adult↗
PubMed1994

Value of elementary, combined, and modeled hemodynamic variables.

PURPOSE: It has been well recognized that the usefulness of the clinical examination and simple hemodynamic variables in the critically ill is limited. Modelization for hemodynamic analysis may improve the diagnostic performance by a systematic and multivariate analysis. This requires a rigorous formalization that may otherwise expand the usefulness of hemodynamic data, both as predictors and as therapeutic targets. Our study was designed to test the value of a model for assessing the pathophysiology of circulatory disorders and for establishing the diagnosis. METHODS: We tested all available variables using survival as the end point. A population of 223 patients (652 measurements) with compromised circulatory status was studied. We evaluated traditional variables: (1) morphological and physical data, (2) elementary right heart catheterization data, and (3) usually calculated variables, versus (4) new modeled variables. These new modeled variables were derived from a previously validated computer program for hemodynamic evaluation. They expressed differences between observed hemodynamic performance and estimated needs. RESULTS: Among traditional variables, major prognostic factors were: (1) in all patients, lactate level elevation, physical signs of hypoperfusion, and a decreased systemic arterial pressure; (2) in septic patients, a high PaO2/SaO2 ratio; (3) in nonseptic patients, low left ventricle work indices. In all cases, modeled hemodynamic variables assessing performance-needs adequacy enhanced the prognostic value of hemodynamic monitoring. CONCLUSIONS: Compared with traditional variables, modeled variables were found of greater interest to quantify pathophysiology of shock. These results enabled us to validate the initial step of the hemodynamic reasonning formalization and to develop "new" diagnostic criteria that more closely fit the interrelationship between pathophysiology, diagnosis, and prognosis.

Algorithms↗
PubMed1994

Enoximone vs nicardipine during the early postoperative course of patients undergoing cardiac surgery. A prospective study of two therapeutic strategies.

The hemodynamic effects of enoximone and nicardipine were compared during the early postcardiac surgery period in 40 patients with systemic hypertension and moderate cardiac dysfunction. Patients were prospectively randomized into two groups. Mean right atrial pressure was maintained above 7 mm Hg. The drug infusion rate was adjusted to maintain mean systemic artery pressure (SAP) within the 65 to 80 mm Hg range. Complete hemodynamic evaluations were performed before any drug infusion and during the following 24 h with special attention to O2-related variables. Oxygen consumption, cardiac index, and stroke index improved significantly and similarly in the two groups. The SAP and systemic vascular resistance decreased more rapidly in the enoximone group but whole body lactate level increased after the second hour of infusion. Furthermore, this was paralleled by an arteriovenous O2 contents difference deficit. In our study, nicardipine was found superior over enoximone in terms of recovery from intraoperative tissue hypoxia. Furthermore, enoximone's inotropic effects were not found to be clinically relevant.

Cardiac Surgical Procedures↗
PubMed1992

[Early postoperative thrombolysis of Saint-Jude aortic valve prosthesis].

The authors report a case of thrombolytic therapy with streptokinase in the early postoperative period after aortic valve replacement with a Saint Jude medical prosthesis. After good initial progress, the patient had to be reoperated on the 12th postoperative day for sternal disunion. Reoperation was followed rapidly by progressive thrombosis of the aortic prosthesis demonstrated by repeated Doppler echocardiographic examination. The impossibility of eliminating mediastinitis led to medical thrombolysis. The outcome was favourable after a regressive cerebral embolic event. This case illustrates the value of Doppler echocardiographic examination in the postoperative period. Thrombolysis may constitute an alternative to reoperation when the operative risk is high. The risk of thrombolysis may not be as great as some believe.

Echocardiography, Doppler↗
PubMed1990

Role of tricuspid regurgitation and left ventricular damage in the treatment of right ventricular infarction-induced low cardiac output syndrome.

To evaluate, in right ventricular (RV) myocardial infarction, the role of tricuspid regurgitation (TR) and left ventricular (LV) damage and the response to treatment of low cardiac output, 20 patients were prospectively studied. Volume infusion increased cardiac output only slightly (11%, p less than 0.001), despite a dramatic increase in ventricular filling pressures. Dobutamine (4 micrograms.kg-1.min-1) markedly increased cardiac output (24%, p less than 0.001) with a decrease in ventricular filling pressures. In the 5 patients with TR, dobutamine only modestly increased cardiac output (9 vs 26%, p less than 0.001), while stroke index and LV end-diastolic dimensions decreased in comparison (-5 vs 33% and -6 vs 9%, respectively, p less than 0.001). In the absence of TR (n = 15), there was no significant difference in response to volume expansion between patients with normal (n = 7) and depressed LV ejection fraction (n = 8). In contrast, dobutamine, in patients with depressed LV function, induced a greater increase in cardiac output (38 vs 17%, p less than 0.01) and RV ejection fraction (36 vs 12%, p less than 0.05). All patients with RV infarction-induced low cardiac output responded only modestly to volume loading. Dobutamine is particularly efficacious in patients without TR who have depressed LV function by improving RV function and, consequently, LV preload. In the 5 patients with TR, increasing RV contractility failed to improve the forward stroke volume by increasing the regurgitant fraction.

Adult↗
PubMed1990

Decreased paradoxic pulse from increased venous return in severe asthma.

During severe asthma, paradoxic pulse may result from increased impedance to left ventricular ejection, mechanical impairment of left ventricular filling by ventricular interdependence or decreased pulmonary venous return augmented by hypovolemia. We studied the effect of reversible blood volume expansion by MAST inflation during severe attacks of asthma. Ten patients with clinically detectable paradoxic pulse of more than 20 mm Hg were studied. All had a history of reversible bronchial asthma with evidence of respiratory and circulatory failure. Standard therapy for asthma was started. We observed no difference in respiratory and heart rates during MAST inflation. Paradoxic pulse was consistently decreased during MAST inflation; paradoxic pulse returned to baseline values after MAST deflation. The decrease in paradoxic pulse was produced by an increased inspiratory systolic arterial pressure. We conclude that a reduction in pulmonary venous return is more important than ventricular interdependence in producing paradoxic pulse during severe asthma.

Adolescent↗
PubMed1986

Frequency of infections in cirrhotic patients presenting with acute gastrointestinal haemorrhage.

The frequency of infection at the time of admission with upper gastrointestinal haemorrhage has been determined in 149 successive cirrhotic patients admitted to an intensive care unit. Infection status was investigated by clinical examination, chest X-ray, and blood, urine and ascitic fluid culture. At initial examination infection was present in 32 patients (22 per cent) and was often in the form of septicaemia or spontaneous peritonitis; the bacteria responsible were frequently digestive in origin. At endoscopy, acute lesions of gastroduodenal mucosa were more frequent among infected patients, whereas gastro-oesophageal varices and chronic gastroduodenal ulcers were more frequent among the non-infected patients. Acute mucosal lesions were observed in 70 per cent of infected patients and in 19 per cent of non-infected patients. The mortality rate was higher in infected patients. Infection and the frequency of acute mucosal lesions were related to the severity of the cirrhosis. It is suggested that these lesions could be due to stress secondary to infection.

Acute Disease↗
PubMed1986

[Aortic insufficiency in certain so-called systemic diseases].

The authors present a retrospective study of all the patient followed up for systemic disease in the rheumatology Department of Bichat hospital between 1975 and 1984 in whom aortic regurgitation developed. Only rare or previously undescribed associations were retained: two MacDuffie syndromes, one adult form of Still's disease, one Takayashu's disease, one association of rheumatoid arthritis and Takayashu's disease, one rheumatoid arthritis, one Cogan's syndrome and two cases of disseminated lupus erythematosis. The authors use these cases and a review of the literature to discuss the possible physiopathological mechanisms of the aortic regurgitation. This study confirms the value of regular clinical cardiovascular examination with echocardiography in cases with progressive symptoms. The evolution of the vascular disease seems to be more or less parallel to that of the systemic disease and in a significant number of cases it becomes sufficiently severe to become the main clinical problem. In our series, there was one sudden death, one death due to cardiogenic pulmonary oedema and three patients required aortic valve replacement.

Adult↗
PubMed1986

[Postpartum myocardial infarction with normal coronary arteries. Apropos of a case].

A case of painless anteroseptal and high lateral wall infarction presenting as cardiogenic shock with pulmonary oedema 24 hours after childbirth complicated by severe post partum haemorrhage with a coagulation defect, is reported. Coronary angiography performed one month later was normal, with a negative ergometrine provocation test. The authors review five previous reports in the medical literature, and discuss the possible physiopathological mechanisms which, alone or in association could have operated in the reported case.

Adult↗
PubMed1985

Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure.

We studied the effects of hypophosphatemia on diaphragmatic function in eight patients with acute respiratory failure who were artificially ventilated. Their mean serum phosphorus level was 0.55 +/- 0.18 mmol per liter (normal value, 1.20 +/- 0.10). The contractile properties of the diaphragm were assessed by measuring the transdiaphragmatic pressure generated at functional residual capacity during bilateral supramaximal electrical stimulation of the phrenic nerves. Diaphragmatic function was evaluated in each patient before and after correction of hypophosphatemia, which was achieved by administration of 10 mmol of phosphorus (as KH2PO4) as a continuous infusion for four hours. After phosphate infusion, the mean serum phosphorus level increased significantly (1.33 +/- 0.21 mmol per liter, P less than 0.0001). The increase in serum phosphorus was accompanied by a marked increase in the transdiaphragmatic pressure after phrenic stimulation (17.25 +/- 6.5 cm H2O as compared with 9.75 +/- 3.8 before phosphate infusion, P less than 0.001). Changes in the serum phosphorus level and transdiaphragmatic pressure were well correlated (r = 0.73). These results strongly suggest that hypophosphatemia impairs the contractile properties of the diaphragm during acute respiratory failure, and they emphasize the importance of maintaining normal serum inorganic phosphate levels in such patients.

Acute Disease↗
PubMed1985

[Hypophosphoremia during mechanical ventilation for chronic obstructive bronchopathies].

Hypophosphoremia may interfere with respiratory function in chronic obstructive pulmonary diseases (COPD) through different mechanisms: muscular exhaustion and weakness. Accordingly, the frequency and magnitude of hypophosphoremia was studied in 36 consecutive patients with acute respiratory failure and mechanical ventilation. Initial phosphoremia was normal (1,32 +/- 0,12 mmol/l) but often and rapidly decreased in all patients after mechanical ventilation had been started (0,54 +/- 0,14 mmol/l after 24 h). After this, phosphoremia remained low, slowly increasing with continued enteral nutrition (2000 Kcal, 276 g of glucides, 33 mmol/l of phosphorus). Four patients had severe hypophosphoremia after 24 h of mechanical ventilation (less than 0,30 mmol/l). Phosphoremia returned to a normal level 36 h after extubation. Hypophosphoremia was closely linked to pH improvement (r = + 0,67, P less than 0,001) and was paralleled by a drop in phosphaturia, suggesting intra-cellular penetration of phosphorus.

Acidosis↗