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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.: (716) 878.7442
Fax: (716) 878.7101
E-mail: arotta@buffalo.edu
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