We use cookies to improve our service and to tailor our content and advertising to you.More infoYou can manage your cookie settings via your browser at any time. To learn more about how we use cookies, please see our cookies policy.
In the case reported by Goyal et al. regarding the presence of a
gastrointestinal tumour in a hernial sac, it appears that poor surgery is
being passed off as a "lesson" to be learnt by the readers. The presence of
a haematoma in an otherwise empty hernial sac should definitely alert the
surgeon to the presence of strangulated bowel which has probably reduced
into the peritoneal cavity. Having ma...
In the case reported by Goyal et al. regarding the presence of a
gastrointestinal tumour in a hernial sac, it appears that poor surgery is
being passed off as a "lesson" to be learnt by the readers. The presence of
a haematoma in an otherwise empty hernial sac should definitely alert the
surgeon to the presence of strangulated bowel which has probably reduced
into the peritoneal cavity. Having made a preoperative diagnosis of an
irreducible inguinal hernia, appropriate measures should have been taken
while delivering the sac inorder to prevent spontaneous reduction so that
the contents can be inspected and if they had landed up in the situation
described in the case report, a laparotomy was mandatory.
The short duration of symptoms should have prompted the caregiver to
think of alternate diagnoses as well.
I feel that these are the "lessons" to be learnt from the case
report.
Professor Nolan deserves congratulation on his excellent editorial on the
need for humanity from doctors towards patients. As someone who has been
involved for years in educating Family Doctors in both the UK and
developing countries I fully endorse all that he says. Experience of
Family Medicine development in many developing countries confirms that
where there has been no culture of compassion or comm...
Professor Nolan deserves congratulation on his excellent editorial on the
need for humanity from doctors towards patients. As someone who has been
involved for years in educating Family Doctors in both the UK and
developing countries I fully endorse all that he says. Experience of
Family Medicine development in many developing countries confirms that
where there has been no culture of compassion or communication from
doctors in the past, the introduction of it to postgraduate medical
training has a very positive impact on the public's perception of doctors
who demonstate these things. Doctors who listen and care because they have
been taught and are consequently motivated to do so are much more popular
than their colleagues who have had no such training.
Even in the UK, before the days of audit and clinical governance it
was tacitly accepted in General Practice that a caring doctor, who might
not be clinically all that hot, would be more respected and loved by
patients than a less caring but more technically competent colleague. The
rise in technical competence by itself will not satisfy patients; they
also want (and should have a right to) doctors who listen and demonstrate
understanding of their concerns.
Despite the great advances in critical care medicine, the mortality
of ARDS is still high. Protective ventilatory strstegy - utilizing lower
tidal volumes and PEEP levels to prevent atelectatic trauma regardless of
arterial oxygenation - has been used in an attempt to reduce the mortality
of ARDS. Both conventional and protective ventialtory strategies
concenterate more on achieving satisfactory arteria...
Despite the great advances in critical care medicine, the mortality
of ARDS is still high. Protective ventilatory strstegy - utilizing lower
tidal volumes and PEEP levels to prevent atelectatic trauma regardless of
arterial oxygenation - has been used in an attempt to reduce the mortality
of ARDS. Both conventional and protective ventialtory strategies
concenterate more on achieving satisfactory arterial oxygenation rather
than tissue oxygenation . In order to do so, FIO 2, PEEP and I:E ratio are
usually adjusted to maintain arterial O2 saturation- SPO2- not less than
90% even at the expense of pulmonary O2 toxicity - due to high FIO2 - and
barotrauma including more and more lung injury - form hihger PEEP and
inverse-ratio ventilation with the potential of Auto-PEEP.According to
protective strategy, PEEP is used - even with acceptable SPO2 - to prevent
atelectato-trauma. When SPO2 is low, PEEP is usually set at higher level
to improve arterial oxygenation. In the clinical setting of ARDS, the
severely-injured lungs may be particularlly more vulnerable to damage from
high FIO2 and PEEP than would be otherwise expected. It may be more
appropriate to concenterate on the tissue oxygenation when dealing with
ARDS patients not only the arterial oxygenation. The tissue oxygenation
can be monitored either directly by measuring the whole-body O2 uptake by
calorimetery or indirectly by calculating the Oxygen extraction ratio ( 02
ER = Sao2-Sao2/Sao2 ) where Sao2 is the arterial O2 saturation and Svo2 is
the mixed venous O2 saturation taken from the pulmonary artery with Swan-
Ganz catheter.Other parameters of tissue oxygenation include gasteric
mucosal pH - mainly representetive of GIT - and arterial blood lactate -
which lack specificity. The tissue oxygenation can be improved and the
tissue hypoxia prevented by increasing the oxygen delivery to the tissues
- DO2 - and decreasing the oxygen uptake - VO2. The Oxygen delivery can be
increased not only by improving the arterial O2 saturation but also by
optimizing the hemoglobin level and improving the cardiac output - QT .
DO2 = 1.34 x Sao2 x Hb x QT. According to the previous equation, it can be
concluded than DO2 (O2 delivery) can be maintained - at least
theoretically - by supra-normal QT (cardiac output) if Sao2 (arterial O2 saturation) is relatively low. The cardiac output may be increased to
supra-normal levels by various inotropic agents - that only minimally
increase the whole-body O2 uptake - such as dobutamine and milrinone. To
achieve supra-normal QT, in addition to the inotropics, volume expantion -
by colloids rather than crystalloids - and vasodilator agents such as
prostacyclin may be used. Prostacyclin is a systemic and pulmonary
vasodilator that can increase the cardiac output and counteract the
expected vasospastic effect of the hypoxemia on the pulmonary vasculature.
Using this tissue oxygenation-oriented approach to ARDS patients, we may
be able to use more protective ventilatory settings - lower levels of
FIO2,PEEP and I:E ratio - and to accept lower levels of arterial O2
saturation as long as the parameters of tissue oxygenation are acceptable,
a method that may be called "permissive hypoxemia". In conclusion, i
hypothesize that maintaining adequate tissue oxygenation - by supranormal
cardiac output - may enable us to use lower levels of PEEP, FIO2 and I:E
ratio and to accept lower levels of SPO2 with the aim of reducing the risk
of pulmonary O2 toxicity, barotrauma and lund injury that may be
particularlly difficult to diagnose in the clinical setting of ARDS.
Reference
HR Smith and DG Sinclair
Severe pulmonary dysfunction following acute respiratory distress syndrome
Postgrad Med J 1996; 72: 555-556
Dear Editor
In the case reported by Goyal et al. regarding the presence of a gastrointestinal tumour in a hernial sac, it appears that poor surgery is being passed off as a "lesson" to be learnt by the readers. The presence of a haematoma in an otherwise empty hernial sac should definitely alert the surgeon to the presence of strangulated bowel which has probably reduced into the peritoneal cavity. Having ma...
Dear Editor
Professor Nolan deserves congratulation on his excellent editorial on the need for humanity from doctors towards patients. As someone who has been involved for years in educating Family Doctors in both the UK and developing countries I fully endorse all that he says. Experience of Family Medicine development in many developing countries confirms that where there has been no culture of compassion or comm...
Dear Editor
Despite the great advances in critical care medicine, the mortality of ARDS is still high. Protective ventilatory strstegy - utilizing lower tidal volumes and PEEP levels to prevent atelectatic trauma regardless of arterial oxygenation - has been used in an attempt to reduce the mortality of ARDS. Both conventional and protective ventialtory strategies concenterate more on achieving satisfactory arteria...
Pages