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Psychological support

The psycho-social needs of the family and the patient

with ARDS are extremely complex. Even in adequately

sedated patients, factors such as anxiety over the uncertainty

of the clinical outcome, the impossibility of speech due to

the artificial airway, the occasional pain due to invasive

procedures and the changes to the awake and sleep cycles,

among others, cannot be neglected by the medical team.

Attention must be afforded to explain to the patient (whenever

possible) and the family all the diagnostic and therapeutic

procedures and also the natural course and prognosis of the

condition. It is common for adolescent patients and older

children in the recovery phase of ARDS to exhibit delirium,

depression or altered circadian patterns during prolonged

hospitalization in an ICU environment. Such manifestations

often require the involvement of a psychiatric consultant to

monitor patients during recovery and after hospital discharge.

The multidisciplinary medical team should always be alert

to and available for the psychological needs of ARDS

patients and their families, particularly because ICU hospital

stays due to severe ARDS are prolonged and generally

marked by oscillation between periods of frustration and

optimism.

Monitoring the patient

Patients with ARDS represent a relatively severe stratum

of the population of a tertiary ICU. As such, these patients

require a high level of monitoring so that data can be

obtained and integrated in real time for individual strategic

treatment planning. Patients with ARDS routinely require

an arterial catheter for continuous arterial pressure

monitoring and for obtaining serial arterial blood gas

analysis. A central venous catheter with two or three

lumens is used for the administration of fluids and drugs

and also for continuous measurement of the central

venous pressure. A urinary catheter permits the precise

measurement of urinary output and control of the fluid

balance. Continuous pulse oximetry is used for real time

assessment of oxygenation. Analysis of exhaled carbon

dioxide curves provides a continuous data for inferring

ventilation, pulmonary perfusion and dead space.

Respiratory monitoring via graphic interfaces allows for

the real time visualization of a series of respiratory

parameters derived from pressure, flow, time and volume.

Serial echocardiography is a good method for monitoring

the degree of atrial filling (preload) as well as the cardiac

function resulting form different combinations of

inotropic drugs and states of intravascular expansion. In

our experience, a pulmonary artery catheter (Swan-Ganz)

has little use in patients with ARDS with no primary

cardiac involvement. The use of such catheters rarely

alters the management based on data obtained from the

auxiliary technologies described above. Patients receiving

continuous neuromuscular blockade should be monitored

with nerve stimulators to avoid the unnecessary use of

exaggerated drug doses.

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Corresponding author:

Alexandre Tellechea Rotta

Division of Pediatric Critical Care,

The Children’s Hospital of Buffalo

219 Bryant Street

Buffalo, NY 14222, USA

Tel.: [phone]

Fax: [phone]

E-mail: [e-mail]

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345:568-73.

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