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Mechanical ventilation and flail chest

parthasarathi goswami parthasarathi013 at yahoo.com
Sun Nov 1 05:20:31 GMT 2009


TO ALL LIST MEMBERS,
 
LET US REMEMBER THAT BEING INTUBATED IS ONE OF THE MOST PAINFUL PROCEDURES THAT HAPPENS IN THE ICU..ALTHOUGH NO BLOOD IS LET OR ANY NEEDLE OR SCALPEL IS USED INTIBATION INCREASES THE STRESS OF THE PATIENTS AND MANY RECOLLECT THAT AS ONE OF THE MOST PAINFUL MEMORIES OF THEIR ICU STAY..ALL PATIENTS ON THE VENT OR INTUBATED MUST RECCIEVE SOME SEDATION AND ANXIOLYSYIS.( DEXMEDETOMIDIDNE PROBABLY FITS THE BILL NICE AND SQUARE)...IT HELPS CALM FRAYED NERVES..MAY ALSO HELP US WEAN PATIENTS FASTER ..AFTER ALL NO ONE WANTS TO GO HOME WITH A NORMAL PHYSIOLOGY BUT A PAINFUL THROAT.AND A BAG OF BAD MEMORIES.
 
DR PARTHASARATHI GOSWAMI
CHIEF ICU COORDINATOR
WOODLANDS HOSPITAL, KOLKATA , INDIA

--- On Sun, 11/1/09, Krin135 at aol.com <Krin135 at aol.com> wrote:


From: Krin135 at aol.com <Krin135 at aol.com>
Subject: Re: Mechanical ventilation and flail chest
To: trauma-list at trauma.org
Date: Sunday, November 1, 2009, 12:45 AM


Dr. Duchesne:

having run into the problem in the past, I modestly recommend that we  
change "paralyzed and sedated" to "sedated and paralyzed," to indicate that the  
sedation/analgesia is the more important phase of the treatment. I've seen 
a  more than few cases (both medical and trauma) of patients on the vent who 
were unstable (tachycardia, labile blood pressure, lousy blood  gases) 
until we increased their sedation. These patients were fully  paralyzed at the 
time. Most of them were lost to my follow up, so I had no way  to ask them 
if they remembered any of the painful procedures (chest tubes,  Foleys) that 
they received while intubated.

I have had more than a few patients in the last 35 years who could relate  
*interesting* anecdotes from the discussions going on during their general  
anesthesia...can be very embarrassing for the docs and nurses  involved!

I've also seen many well sedated patients that did not need paralysis to  
tolerate even painful ventilation.

ck


In a message dated 10/31/2009 11:44:56 Central Standard Time,  
jduchesn at tulane.edu writes:

Dear  Matthieu:
I have my own bias on what works for lung contusion with severe  chest wall 
injury (flail chest) and ARDS net is not the answer.
I like to  use damage control ventilation using pressure control at low 
rate with a 1 to  1 I:E ratioa. This works great in opening your FRC. I 
identify the best PEEP  and then add Pressure above PEEP to give you a Plateau at 
33. For this  maneuver the patient needs to be paralyzed and sedated in order 
to achieve the  best recruitment.
I use this damage control ventilation mode for the first  72 hours and 
although I don't have our own data yet the CXR difference is  dramatic.
Good Luck
Duchesne
CharityOne-New Orleans
Sent via  BlackBerry by AT&T

-----Original Message-----
From: Matthieu G.  <mat.genz at gmail.com>
Date: Sat, 31 Oct 2009 18:13:49 
To:  Trauma-List [TRAUMA.ORG]<trauma-list at trauma.org>
Subject: Mechanical  ventilation and flail chest

Dear list members,

do you use a  specific mechanical ventilation strategy for patient with  
flail  chest and underlying lung contusions, besides the lung  
protective  approach for patient with ALI/ARDS? For example, Moore's  
Trauma  textbook advocates the use of volume controlled over pressure- 
supported  mode, the rationale being that even the modest negative  
pressures  needed to trigger the ventilator cycle may destabilize the  
chest  wall.

Thank you for your input.

Matthieu  Gensburger

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