Acute lung Injury

• The use of high tidal volume and high respiratory rate are independent predictors of acute lung injury in patients with severe brain injury. In this patient population, alternative ventilator strategies should be considered to protect the lung and guarantee a tight CO2 control.
• Early acute lung injury/acute respiratory distress syndrome is characterized by decreased plasma levels of protein C and increased plasma levels of plasminogen activator inhibitor-1 that are independent risk factors for mortality and adverse clinical outcomes. Measurement of plasminogen activator inhibitor-1 and protein-C levels may be useful to identify those at highest risk of adverse clinical outcomes for the development of new therapies.

Transfer of Critically ill

Usually these patients are ventilated and on cardiovascular support. It involves lot of gadget to transfer these patients.

For an uneventful transfer be it intra- or inter hospital transfer the following tips will help:

1. Adequate oxygen supply - twice that required for the journey
2. Fully charged ventilator
3. Fully charged monitor - minimum monitoring should include ECG, SPO2, BP either IBP/NIBP, ETCO2.
4. Adequate nitric oxide if used. Proper connectors should be ready.
5. Emergency Drugs- Atropine, Adrenaline(1/1000 and 1/10000 dilutions), metaraminol(1mg/ml in 10 ml), saline flushes should be present atleast.
6. Anaesthetic drugs - Muscle relaxant(paralyse a ventilated patient before transfer), Fentanyl/Alfentanil or morphine infusion(if already on that in ICU).
7. Fluids - Colloids - Gelofusine, hetastarch, blood(if low Hb)
8. Minimise things to be transferred - like KCl, Actrapid or frusemide infusion.
9. Adequate staff to transfer.

Endoscopic Coronary Artery Bypass Graft

Goals:
1. Normotensive
2. Normothermic
3. Maintain normal electrolytes
4. Avoid tachycardia or bradycardia

Approach:
Left thorocoscopic for dissection of left internal mammary artery.
Left parasternal thoracotomy in 4th intercostal space for LIMA to LAD aastamosis.

Requirements:
1. Venous access and radial arterial line in right hand
2. One lung ventilation. Left lung can be collapsed either with double lumen tube or use of broncial blocker with single lumen tube.
3. Left internal jugular access.
4. External warming device.
5. Perfusionist fully prepared for CPB if required.
6. Heparin just before clamping the LIMA, half to full dose depending on the local practice.
7. Post op pain relief - PCA morphine is what we ususlly follow. Other options include - thoracic epidural, PCA alfentanil.