The portable lateral film, like the decubitus films, are not often obtained in the ICUs but can better delineate the costophrenic sulci and the frequently obscured lower lobes to advantage. The lateral film is particularly useful when only one lower lobe is involved since the normal lung can provide a window to the opposite lung without the confusion of laterality. Both the decubitus and the lateral films can significantly increase the awareness of basal lung disease, unsuspected on the portable AP films.
A 68-year-old woman had previously undergone multiple surgical procedures for peptic ulcer disease. She developed a recurrent upper gastrointestinal hemorrhage and underwent laparotomy at a local hospital. When this procedure did not reveal the source of bleeding, the patient was transferred to our hospital in hypovolemic shock. A left thoracotomy was performed, and the aorta was crossclamped for control of hemorrhage. Laparotomy revealed a bleeding gastroesophageal ulcer. The ulcer was oversewn, and the patient was taken to the ICU. A week after the operation, the patient developed signs of peritonitis and sepsis. An abdominal CT documented extravasation of gastrointestinal contrast, thus supporting the clinical diagnosis of colonic perforation. After colostomy and drainage, the patient was transiently stabilized, but later deteriorated. Abdominal CT, routine cultures, and multiple portable chest roentgenograms were nondiagnostic.
A 38-year-old morbidly obese woman underwent a subtotal small bowel resection at her local hospital for intestinal infarction due to polyarteritis nodosa. She subsequently developed sepsis and pulmonary insufficiency and was transferred to our hospital, After hemodynamic stabilization, a laparotomy, with near-total small bowel resection and drainage of intra-abdominal abscesses, was performed. Postoperatively, she developed pulmonary, renal, and hepatic failure with an accompanying encephalopathy Cultures of sputum grew Pseudomonas sp. A right pneumothorax developed and was treated with tube thoracostomy. She then developed and was treated with tube thoracostomy.
The portable chest roentgenogram is one of the most frequent and effective diagnostic examinations used in the intensive care unit. It is easily obtained and frequently demonstrates most pathologic conditions, but does have shortcomings. Because a significant portion of the lower lobes lie below the diaphragmatic domes, pathologic findings in these areas may be obscured or unidentifiable on the portable chest roentgenogram. Under these circumstances, more sophisticated imaging techniques, including computed tomography (CT), may be required to clearly define the extent of the disease process. This report presents three instances in which the portable chest roentgenogram, while far from normal, fails to demonstrate the full extent of chest pathologic conditions accounting for a significant proportion of the patients overall clinical condition.
In this report, we describe an asthmatic child who had marked variations in theophylline clearance, in association with co-administration of isoproterenol and albuterol. The T/cl values measured in our patient at times when no sympathomimetics were delivered resembled those previously reported in children of this age. It has been shown that intravenous infusion of isoproterenol increased T/cl in six asthmatic children treated for status asthmaticus. The T/cl in our patient during simultaneous infusion of theophylline and isoproterenol was higher than before institution of the latter. Since isoproterenol has a very short half-life, it is reasonable to assume that several hours after its discontinuation, no further circulating isoproterenol was present. Therefore, the increased T/cl observed during the intravenous albuterol therapy suggests a possible role for albuterol to this effect. Furthermore, the unplanned break in albuterol infusion was associated with a decrease in T/cl which supports this assumption. Indeed, reproducibility of the effect was demonstrated later, when during the second period of albuterol infusion, the T/cl increased by approximately 60 percent, whereas discontinuation of albuterol at the end of the treatment resulted in a reduction of the clearance.
Theophylline has a relatively low therapeutic index, ie, a narrow therapeutic-toxic serum concentration range, and since both its bronchodilatory efficacy and toxicity are related to its serum concentrations, it is important to recognize factors which might influence theophylline levels. Drug interaction has been reported between theophylline and erythromycin, cimetidine, phenobarbital, propranolol, isoproterenol, and terbutaline. Both isoproterenol and terbutaline2 have recently been shown to increase theophylline clearance in asthmatic children. Albuterol is another p-agonist extensively used in the management of acute asthma in conjunction with theophylline. We report a child who received continuous intravenous theophylline for the treatment of status asthmaticus and whose theophylline clearance was increased by intravenous administration of albuterol. buy antidepressants online
Left ventricular pseudoaneurysm formation results usually as a complication of acute myocardial infarction. However, this anomaly can be associated with several other etiologies. Until recently, a firm diagnosis of this entity relied on cardiac angiography. The advent of two-dimensional echo cardiography made feasible the noninvasive identification of the false aneurysm, but in certain cases, the characteristic narrow neck communicating between the left ventricle and the false chamber can not be seen. The combined utilization of pulsed wave Doppler can help to establish a firm diagnosis in these circumstances, by detecting a turbulent systolic flow pattern across the point of communication, even if the connection between both chambers is not clearly visualized. diabetes medications