No abstract

An estimated 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. As a condition that disproportionately affects the elderly and is related to invasive and immunosuppressive healthcare, increases in the frequency of sepsis are anticipated. The complex pathophysiology of sepsis encompasses the interplay of pro- and anti-inflammatory mediators, activated circulating and resident inflammatory cells, disrupted coagulation, endothelial activation and injury, vasodilatation and vascular hyporesponsiveness to vasoactive mediators, cardiac dysfunction, and cellular dysoxia. Current management of severe sepsis includes eradication of infection through source control and antimicrobial therapy, aggressive and targeted shock resuscitation that includes fluid administration, correction of anemia, vasopressor support, modest inotropic therapy, infusion of human recombinant activated protein C to selected patients, and compulsive supportive care to manage organ dysfunction and to avoid complications.

Airway pleural fistulas remain a significant treatment challenge despite improved antimicrobial therapy and surgical techniques. We present a case of a 56-year-old female who was admitted with severe bilateral cavitary pneumonia requiring mechanical ventilation. The patient suffered bilateral pneumothoraces related to necrotic pneumonia resulting in bilateral chest tube placement. Despite conservative measures, the air leak persisted preventing chest tube removal. Bronchoscopy with Fogarty balloon (Edwards) occlusion was performed in attempts to isolate an airway responsible for the air leak. No one single airway could be bronchoscopically occluded to isolate the right-sided fistula. Efforts were focused on the left airway where the fistula could be isolated to the anteromedial basal segment. Several alternating layers of an absorbable hemostat (knitted fabric prepared by controlled oxidation of cellulose-Surgicel; Ethicon) were placed within the left anteromedial basal segment using bronchoscopy forceps. Through a cut Fogarty balloon, 3 mL of the patient's blood was delivered onto the absorbable hemostat to create an occluding blood patch. No air leak was present at the completion of the procedure. While on mechanical ventilation, the left chest tube was removed 2 days later without radiographic recurrence of her pneumothorax.

Intravenous injections of adrenaline and noradrenaline in man cause a striking increase in the rate and depth of respiration. This is associated with a fall in the alveolar CO2 content and an increase in the respiratory minute volume. The hyperpnoea is abrupt in onset and does not appear to be accounted for by a general increase in metabolic rate (Whelan and Young, 1953).The present experiments were carried out in an attempt to determine if the stimulant effect of adrenaline and noradrenaline on respiration in man is the result of a direct action on the respiratory or other centre in the brain. METHODSThe subjects were patients on whom cerebral angiography was being carried out for diagnostic purposes. Following the first injection of contrast medium, an interval elapsed, while the films were developed and studied, before further injections were made. Advantage was taken of this interval to infuse small doses of adrenaline or noradrenaline and record their effects on respiration.The patients lay supine with the head extended. The respiratory movements were recorded by means of two stethographs, one around the chest and the other around the abdomen (Shepherd, 1951;Dornhorst and Leathart, 1952). These were connected to a volume recorder which traced the movements with an ink writer on a kymograph drum.Direct Infusion into the Common Carotid Artery. -Under local anaesthesia with 10-20 ml. of 1% (w/v) procaine, a needle, 9.5 cm. long and 2 mm. in external diameter with a short bevel, was inserted into the common carotid artery. The needle was connected to a mechanically-driven syringe by a length of polythene tubing. An infusion of 0.9% saline was maintained throughout at a rate of 4 ml./min. and was interrupted when required either for injection of contrast medium or for the infusion of adrenaline or noradrenaline solutions.

Inspection bronchoscopy during percutaneous dilational tracheostomy has become the standard of care to reduce complications of the procedure. During bronchoscopy, anatomic defects can be visualized before performing the procedure. We describe a case of discovering herniated tracheal rings in preprocedure bronchoscopy and subsequent treatment of this rare finding.