Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: DISCUSSION part 2

In an effort to define our patient population, we have utilized the classification system in Table 2. The classification we propose separates patient populations based on the duration of the ARDS. We reason that by defining established ARDS as beginning at 72 hours, the causative process will have been controlled in those patients. We further divided the established ARDS group into those with isolated ARDS or com­plicated ARDS (additional organ dysfunction) since we reasoned mortality should be related to the com­plexity of the clinical problems. Five of our patients had uncomplicated ARDS which may be an explana­tion for our good results. Since our report is an uncontrolled experience, we used the work of Mont­gomery and associates on the natural history of ARDS for comparison. It is the only data from which mortality of patients with what we have defined as established ARDS can be calculated.

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Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: DISCUSSION

The three patients we have presented in detail demonstrate responses of ARDS to a sustained course of ACS. In the first two patients, short ACS trials resulted in temporary, limited responses in clinical condition, oxygenation, and roentgenographic abnor­malities which regressed when the dosage was re­duced. Subsequently, longer therapeutic trials re­sulted in a resolution of these abnormalities. Prolonged unimproving cases of ARDS responded to sustained courses of ACS as in cases 1 and 3. Our experience, although limited and uncontrolled, suggests an impor­tant role for a sustained course of ACS in the treatment of selected ARDS patients with established disease. These observations enhance our perspective and un­derstanding of ARDS and do not conflict with other published work.

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Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: TOTAL EXPERIENCE

Ten patients have been treated with a program of sustained ACS for established ARDS including the three described above (Table 1). In all patients, the initiating event(s) had resolved prior to the use of ACS. The ARDS had been present from four to 40 days before the ACS program was initiated (average-11 days). The etiologies of ARDS in our patients were sepsis, aspiration, and trauma (one patient each); cardiopulmonary arrest (two patients); and post-pump cardiopulmonary bypass (five patients). The ACS ther­apy was longer than three weeks in all surviving patients and a dosage of greater than 40 mg a day was employed for an average of 12 days. Patients 3 through 10 were all treated with uninterrupted courses of ACS (Table 1). Their responses to ACS were similar to that demonstrated in patient 3 (Fig 4) except for case 6 who died. After four to seven days of therapy, signifi­cant clinical improvement in ventilatory requirements, oxygenation, and chest roentgenograms were apparent in all patients. Nine Ga citrate scans were performed in eight patients. Significant uptake was observed in all scans (Table 1 and Fig 3).

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Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: PATIENT PROFILES AND CLINICAL TECHNIQUES part 2

Case 2

One week following an acute myocardial infarction, a 37-year-old native American woman (Fig 2) required emergency replacement of the mitral valve for severe acute mitral regurgitation. The postoperative course was complicated by diffuse pulmonary infil­trates and prolonged ventilator dependence. By the seventh hospital day, there had been no improvement in the ARDS in spite of supportive measures. Hemodynamic measurements showed a wedge pressure of 19 mm Hg and pulmonary artery pressures of 43/29. A ^Ga citrate scan demonstrated significant pulmonary uptake of isotope at 48 hours (Fig 3). A rapidly tapering dose of ACS was given, and distinctive improvements in oxygenation and chest roentgenogram were observed. The patient was successfully weaned from mechanical ventilation and extubated. However, the patient, who had been improving daily, began to deteriorate without apparent reason.

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Established ARDS Treated with a Sustained Course of Adrenocortical Steroids: PATIENT PROFILES AND CLINICAL TECHNIQUES

Ten patients with established ARDS were cared for by the authors over an 18-month period and represent our total experience with ARDS treated with ACS since the index case (Table 1). The first two patients initially had a limited course of ACS, but subsequently completed a sustained course of greater than 21 days. Seven patients had uninterrupted courses of therapeutic ACS for greater than 21 days while one died during therapy.

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Established ARDS Treated with a Sustained Course of Adrenocortical Steroids

The word, “controversy,” is repeatedly used to describe the debate surrounding the use of ACS in patients suffering from ARDS. Prominent clinicians and scientists are on opposite sides of the issue quoting well-done work to support their views. Recent carefully performed studies have shown short-term, high-dose adrenocortical steroids do not improve ul­timate outcome. Our experience has led us to question further the use of these agents in this complicated problem. What is the effect of a longer course of therapy? Can patient selection identify a group or subset who may respond to this therapy? What are the implications of gallium uptake by ARDS lungs for pathogenesis and therapy?

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Echocardiographic Observations in Survivors of Acute Electrical Injury: DISCUSSION

There is little information available concerning the 104 cardiac sequelae in survivors of electrical shock. Electrocardiographic patterns typical of acute myo­cardial infarction have been reported immediately after resuscitation, but it has been suggested that in long-term survivors these resolve completely. To our knowledge, only one previous report has provided any direct information concerning cardiac function in such patients. Lewin et al reported the noninvasive car­diac findings in a 19-year-old who was successfully resuscitated following an electrical injury. An echocar­diogram performed at the time of cardiac enzyme elevation and striking ECG abnormalities demon­strated severe global left ventricular hypokinesis. However, a follow-up echocardiogram three days later showed significantly improved ventricular function, and a gated blood pool scan performed at that time demonstrated an ejection fraction of 69 percent. A repeat echocardiogram at one year was entirely nor­mal. In contrast, the two patients described herein had persistent abnormalities of left ventricular func­tion. In one, although there was a marked reduction in the extent of dysfunction noted initially, left ven­tricular apical dyskinesis persisted. In addition, two months later, a thallium scan demonstrated a fixed perfusion defect consistent with apical infarction. In the second patient, there was severe biventricular dysfunction that persisted until death at day 6.

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