Showing papers in "Current Opinion in Critical Care in 2011"
TL;DR: Clinicians should be aware of organizational approaches such as the ‘ABCDE’ bundle to improve the management of mechanically ventilated patients and apply evidence-based therapies for the 'liberation' from mechanical ventilation and sedation, and the 'animation' through early mobilization.
Abstract: Purpose of reviewDelirium and ICU-acquired weakness are frequent in critically ill mechanically ventilated patients. The number of mechanically ventilated patients is increasing, placing more patients at risk for these adverse outcomes. Sedation is given to ensure comfort and to minimize distress, b
315 citations
TL;DR: Sepsis is viewed as an excessive host response to pathogen inducing a complex network of molecular cascades leading to tissue damages, organ failures, and death.
Abstract: Purpose of reviewTo describe the pathogenesis and emphasize prognosis of systemic inflammatory response during severe infection.Recent findingsHost immune response enables to confine and clear microorganisms. Sometimes for current unknown reason depending on host (genetic susceptibilities and comorb
223 citations
TL;DR: There is emerging evidence that decreased preoperative cognitive function contributes to the development of postoperative delirium and POCD, and Randomized controlled trials evaluating interventions to improve long-term cognitive outcomes in elderly patients are urgently needed.
Abstract: Purpose of review
The elderly are the fastest growing segment of the population and undergo 25–30% of all surgical procedures. Postoperative cognitive problems are common in older patients following major surgery. The socioeconomic implications of these cognitive disorders are profound; cognitive decline is associated with a loss of independence, a reduction in the quality of life, and death. This review will focus on the two most common cognitive problems following surgery: postoperative delirium and postoperative cognitive dysfunction (POCD).
199 citations
TL;DR: A fluid challenge identifies and simultaneously treats volume depletion, whilst avoiding deleterious consequences of fluid overload through its small volume and targeted administration.
Abstract: Purpose of reviewThe fluid challenge is used in the fluid management of many sick patients. The principle behind the fluid challenge technique is that by giving a small amount of fluid in a short period of time, the clinician can assess whether the patient has a preload reserve that can be used to i
197 citations
TL;DR: Awakening from postanoxic coma is increasingly observed, despite early absence of motor signs and frank elevation of serum markers of brain injury, suggesting a new multimodal approach to prognostication is therefore required, which may particularly improve early prediction of favorable clinical evolution after cardiac arrest.
Abstract: Purpose of reviewTherapeutic hypothermia and aggressive management of postresuscitation disease considerably improved outcome after adult cardiac arrest over the past decade. However, therapeutic hypothermia alters prognostic accuracy. Parameters for outcome prediction, validated by the American Aca
159 citations
TL;DR: Acute-on-chronic liver failure may be a distinct clinical entity with a potential for reversibility when identified early and managed with aggressive critical care support.
Abstract: Purpose of reviewA population of patients with previously compensated cirrhosis will develop acute deterioration resulting in multiorgan failure and high short-term mortality. Complications of cirrhosis frequently culminate in admissions to the ICU. This review advances the concept of acute-on-chron
155 citations
TL;DR: Although new biomarkers are being developed, the ‘tried and true’ markers of serum creatinine and urine output, disciplined by current criteria, will be important components in the definition and classification of AKI for some time to come.
Abstract: Purpose of reviewAcute kidney injury (AKI) is a common clinical syndrome whose definition has standardized as a result of consensus by leading experts around the world. As a result of these definitions, reported AKI incidences can now be compared across different populations and settings. Evidence f
129 citations
TL;DR: Thoracic epidural, thoracic paravertebral, and intercostal blocks are the top choices for patients with MFR and they are of equivalent efficacy, each has unique advantages and disadvantages.
Abstract: Purpose of reviewThoracic trauma leading to multiple fractured ribs (MFR) remains very common. Good analgesia may help to improve a patient's respiratory mechanics and to avoid intubation of the trachea for ventilatory support and therefore may dramatically alter the course of recovery. We herein re
120 citations
TL;DR: Development of an appropriately accurate and parsimonious measure of ICU capacity strain may augment the precision of future critical care outcomes research by reducing unexplained variance attributable to temporal fluctuations in ICU-level factors.
Abstract: Purpose of review Increasing demand for critical care, with limited potential for comparable expansion of supply, may strain the abilities of ICUs to provide high-quality care in an equitable fashion. Efforts to counter the untoward consequences for the quality and ethics of critical care delivery are limited by the absence of a specific and validated metric of ICU capacity strain. Recent findings This manuscript presents a conceptual framework for ICU capacity strain, considers what data elements may contribute to it, and suggests methods for determining the optimal metric. Next, it outlines the range of potential consequences of increased capacity strain, in terms of both the quality and ethics of care delivered. Finally, consideration is given to how untoward consequences of ICU capacity strain might be mitigated through better understanding of what makes some ICUs better able than others to withstand temporal fluctuations in the demand for their services. Summary Development of an appropriately accurate and parsimonious measure of ICU capacity strain may augment the precision of future critical care outcomes research by reducing unexplained variance attributable to temporal fluctuations in ICU-level factors; elucidate organizational characteristics that make some ICUs better able to withstand high-capacity strain without substantive degradations in quality; and enhance the transparency of critical care rationing while helping to improve its equity and efficiency, thereby promoting the ethics of this inevitable practice.
110 citations
TL;DR: As the epidemiology of antibiotic resistance in ICUs is rapidly changing toward more frequently occurring epidemics and endemicity of multi and panresistant Gram-negative pathogens, better infection control and improved diagnostics will become even more important than before.
Abstract: Purpose of reviewAntimicrobial resistance is an emerging problem in ICUs worldwide. As numbers of published results from national/international surveillance studies rise rapidly, the amount of new information may be overwhelming. Therefore, we reviewed recent trends in antibiotic resistance in ICUs
95 citations
TL;DR: Extensive literature demonstrates that propofol, ketamine, midazalam, and fentanyl are appropriate medications with proper monitoring and the presence of appropriate personnel for ED sedation and analgesia.
Abstract: PURPOSE OF REVIEW Procedural sedation and analgesia is frequently administered outside of the operating room in emergency departments (EDs) and ICUs. Evidence was sought concerning patients' safety in the ED. RECENT FINDINGS Procedural sedation, when administered in the ED by trained personnel, is safe. Extensive literature demonstrates that propofol, ketamine, midazalam, and fentanyl are appropriate medications with proper monitoring and the presence of appropriate personnel. Preprocedural fasting may not be necessary in many cases. SUMMARY With appropriately trained personnel, proper equipment, and the studied drugs ED sedation and analgesia is safe and an appropriate procedure.
TL;DR: Attributable mortality of VAP is about 6%.
Abstract: Purpose of review To critically discuss the attributable mortality of ventilator-associated pneumonia (VAP) and potential sources of variation. Recent findings The review will cover the available estimates (0-50%). It will also explore the source of variation because of definition of VAP (being lower if inaccurate), case-mix issues (being lower for trauma patients), the severity of underlying illnesses (being maximal when the severity of underlying illness is intermediate), and on the characteristics and the severity of the VAP episode. Another important source of variation is the use of poorly appropriate statistical models (estimates biased by lead time bias and competing events). New extensions of survival models which take into account the time dependence of VAP occurrence and competing risks allow less biased estimation as compared with traditional models. Summary Attributable mortality of VAP is about 6%. Accurate diagnostic methods are key to properly estimating it. Traditional statistical models should no longer be used to estimate it. Prevention efforts targeted on patients with intermediate severity may result in the most important outcome benefits.
TL;DR: Sepsis can be seen as a PRR-mediated dysregulation of the immune system following pathogen invasion in which a careful balance between inflammatory and anti-inflammatory responses is vital.
Abstract: Purpose of reviewSepsis continues to be a leading cause of ICU death. This review summarizes current knowledge on sepsis pathogenesis and new therapeutical strategies.Recent findingsAlthough systemic inflammatory response syndrome predominates in early sepsis, the compensatory anti-inflammatory resp
TL;DR: This review focuses on the major epidemiologic trends and novel treatments for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, Clostridium difficile, and multidrug-resistant Gram-negative bacilli in the United States during 2010–2011.
Abstract: Purpose of reviewAntimicrobial resistance and a paucity of new antimicrobial agents are ongoing challenges. This review focuses on the major epidemiologic trends and novel treatments, when available, for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus, Clostridi
TL;DR: Elucidation of the pathophysiological mechanisms bi-directionally linking MOF to ARDS appears to be a promising area of research that hopefully will lead to improved outcomes for these devastating conditions.
Abstract: Purpose of reviewDespite improvements in outcome due to lung protective ventilation strategies using low tidal volumes, the mortality rate from acute respiratory distress syndrome (ARDS) remains unacceptably high, ranging from 34 to 64%. The predominant cause of death in ARDS is not severe hypoxemia
TL;DR: Routine RV function assessment leads to an approach to mechanical ventilation in ARDS patients designed for protection of the right ventricle, called ‘RV protective approach’, associated with prone positioning, a method of ventilation that improves RV function.
Abstract: Purpose of reviewTo reiterate the effects of positive pressure ventilation on right ventricular (RV) function in acute respiratory distress syndrome (ARDS), to explain in which conditions acute cor pulmonale (ACP) may worsen prognosis, and to define an approach to protection of the right ventricle.R
TL;DR: The semirecumbent position has proven benefits and should be routinely used but there is still limited evidence to recommend the lowest orientation of the bed at which the patient can be safely maintained, as there is clear evidence that the supine horizontal body position increases risks of pulmonary aspiration and VAP.
Abstract: Purpose of reviewVentilator-associated pneumonia (VAP) is a lung infection commonly acquired following tracheal intubation. This review assesses the role of the supine semirecumbent and the prone position as VAP preventive strategies and calls attention for further investigation on novel body positi
TL;DR: Clinical experience and reported data suggest that patients with hypertensive urgencies are frequently inappropriately treated with intravenous antihypertensive agents, whereas patients with true hypertensive emergencies are overtreated with significant complications.
Abstract: Purpose of reviewSystemic hypertension (HTN) is a common medical condition affecting over 1 billion people worldwide. One to two percent of patients with HTN develop acute elevations of blood pressure (hypertensive crises) that require medical treatment. However, only patients with true hypertensive
TL;DR: Recent developments in bystander CPR have simplified arrest recognition and improved CPR training, while retaining CPR effectiveness, and the goal is to increase and improve bystanders' CPR and in turn improve resuscitation.
Abstract: Purpose of review Summary estimates indicate that bystander cardiopulmonary resuscitation (CPR) can improve the chances of out-of-hospital cardiac arrest survival two-fold to three-fold. And yet, only a minority of arrest victims receive bystander CPR. This summary will review the challenges and approaches to achieve early and effective bystander CPR. Recent findings Given the host of barriers, a successful strategy to improve bystander CPR must enable more timely and comprehensive arrest identification, encourage and empower bystanders to act, and help assure effective CPR. Arrest identification can be simplified so that bystanders should start CPR when a person is unconscious and not breathing normally. Evidence from observational studies and interventional trials supports the effectiveness of chest compression-only CPR for bystanders. As a consequence, the emphasis of bystander CPR training has been modified to feature and assure chest compressions. Bystanders should initiate CPR with compressions and consider the addition of rescue breathing based on their CPR training and skills as well as special circumstances of the victim. Bystander CPR training has evolved to incorporate this emphasis. Although general community-level CPR training remains a cornerstone strategy, training directed to those most likely to witness an arrest also has a useful role. In particular, 'just-in-time' dispatcher-assisted CPR instruction can increase bystander CPR and improve the likelihood of survival. Summary Recent developments in bystander CPR have simplified arrest recognition and improved CPR training, while retaining CPR effectiveness. The goal of these developments is to increase and improve bystander CPR and in turn improve resuscitation.
TL;DR: Compared the physiology and consequences of breathing patterns that preserve and eliminate breathing effort has been a theme of persisting investigative interest throughout the several decades over which it has been possible to sustain cardiopulmonary life support outside the operating theater.
Abstract: Purpose of reviewTo present an updated discussion of those aspects of controlled positive pressure breathing and retained spontaneous regulation of breathing that impact the management of patients whose tissue oxygenation is compromised by acute lung injury.Recent findingsThe recent introduction of
TL;DR: Major unexplored research and public health questions remain unanswered regarding the worldwide burden of critical illness, variation in resources available for treatment, and strategies to prevent and treat critical illness that are broadly effective and feasible.
Abstract: Purpose of reviewInterest in the global burden of critical illness is growing, but comprehensive data to describe this burden and the resources available to provide care for critically ill patients are lacking.Recent findingsChallenges to obtaining population-based global estimates of critical illne
TL;DR: Liver support systems are safe and well tolerated when used in management of patients with ACLF and should continue in controlled clinical trials to explore their role in bridging patients to liver transplantation or recovery in well defined patient groups.
Abstract: Purpose of reviewAcute-on-chronic liver failure (ACLF), a syndrome precipitated by acute liver injury in patients with advanced cirrhosis, is associated with multiorgan dysfunction and high rates of mortality. Liver support systems have been developed in an attempt to improve survival of patients wi
TL;DR: Despite competition with less invasive hemodynamic monitoring devices or ultrasonic methods, the PAC remains a useful monitoring device in situations in which the knowledge of pulmonary artery pressure, pulmonary artery occlusion pressure and oxygenation parameters are needed.
Abstract: Purpose of review Hemodynamic monitoring has gained widespread acceptance in intensive care units. Despite ongoing debate regarding its safety and efficacy, monitoring with the pulmonary artery catheter (PAC) remains used for the management of severe heart failure and shock. Recent findings To reanalyze using the most recently published literature in the field, the role of the PAC to manage critically ill patients with right ventricular failure, pulmonary hypertension and weaning failure from cardiac origin. The role of PAC as a gold standard to validate new cardiac output monitoring devices was also reported. Summary Despite competition with less invasive hemodynamic monitoring devices or ultrasonic methods, the PAC remains a useful monitoring device in situations in which the knowledge of pulmonary artery pressure, pulmonary artery occlusion pressure and oxygenation parameters are needed. The proper use of PAC requires, however, a perfect knowledge of the numerous pitfalls and difficulties in interpretation of its measurements.
TL;DR: H1N1 2009 has emerged as an important cause of ARDS in 2009–2010 and available evidence suggests that early antiviral treatment improves outcomes from H1n1 2009.
Abstract: Purpose of reviewTo review the literature on novel swine origin influenza A (H1N1 2009) as a cause of respiratory failure and acute respiratory distress syndrome (ARDS).Recent findingsH1N1 2009 was first recognized as a pathogen in March of 2009, when there was a spike in the number of cases of infl
TL;DR: Dysnatremias, disorders of sodium concentration, are exceedingly common in critically ill patients and confer increased risk for adverse outcomes including mortality and the potential for prevention or earlier recognition and intervention is emphasized.
Abstract: Purpose of review Dysnatremias, disorders of sodium concentration, are exceedingly common in critically ill patients and confer increased risk for adverse outcomes including mortality. The physiology that underpins the diagnosis and management of these disorders is complex. This review seeks to discuss current literature regarding the pathophysiology, diagnosis, epidemiology, and management of these disorders. Recent findings The role of arginine vasopressin in the maintenance of normal and pathologic plasma osmolality increasingly is refined, improving our ability to diagnose and understand dysnatremia. Identified recent epidemiologic studies highlight the frequent hospital acquisition or exacerbation of dysnatremia, confirm the recognized adverse consequences and explore the potential causality. Despite the complex nature of these disorders, simple consensus treatment strategies have emerged. Summary Dysnatremia remains a common disorder across the spectrum of critically ill patients. It is frequently hospital acquired. Simplified treatment regimens are proposed and the potential for prevention or earlier recognition and intervention is emphasized. Future directions of interest include further exploration of how dysnatremia contributes to adverse outcomes and new treatment strategies.
TL;DR: A well organized, multimodal therapy optimizing intracranial and systemic physiological variables improves outcome after ICH, and recent guidelines provide a useful consensus evidence-based framework.
Abstract: Purpose of reviewSpontaneous intracerebral hemorrhage (ICH) is associated with high morbidity and mortality, providing substantial scope for improvements in outcome. This review will discuss recent developments and present consensus evidence for the management of ICH.Recent findingsIntracranial mana
TL;DR: The benefit of supplemental oxygen during cardiopulmonary resuscitation remains uncertain, however, available evidence supports adjusting inspired oxygen content to avoid arterial hyperoxemia while providing adequate arterial oxyhemoglobin saturation.
Abstract: Purpose of reviewReversal of tissue hypoxia, particularly in the heart and brain, is a fundamental goal of cardiopulmonary resuscitation. However, a growing body of evidence suggests that hyperoxia, especially after return of spontaneous circulation (ROSC), may worsen outcomes. The purpose of this r
TL;DR: A greater appreciation of the timing of assessment, leucocyte subsets and the extended inflammatory response will be discussed, and a large body of evidence from ischaemic injuries suggests that inhibition of leucocytes can reduce injury and improve outcome.
Abstract: Purpose of review This review will consider the reasons why the inhibition of leucocyte recruitment after traumatic brain injury has not been demonstrated but should remain an area of active interest. Recent findings Focal lesions to the brain display a characteristic inflammatory response with infiltration of peripheral immune cells after injury. These cells are believed to be important because they contain and release a multitude of inflammatory mediators associated with increased tissue injury. Furthermore a large body of evidence from ischaemic injuries suggests that inhibition of leucocyte recruitment can reduce injury and improve outcome. However, therapeutic efficacy has not been demonstrated in clinical trials and for traumatic injuries the results are less convincing. Summary A greater appreciation of the timing of assessment, leucocyte subsets and the extended inflammatory response will be discussed.
TL;DR: There is growing evidence that supports EIT usage as a bedside measure to individually optimize ventilator settings in critically ill patients in order to prevent ventilATOR-induced lung injury.
Abstract: Purpose of review Electrical impedance tomography (EIT) is an attractive method of monitoring patients during mechanical ventilation because it can provide a noninvasive continuous image of pulmonary impedance, which indicates the distribution of ventilation. This article will discuss ongoing research on EIT, with a focus on methodological aspects and limitations and novel approaches in terms of pathophysiology, diagnosis and therapeutic advancements. Recent findings EIT enables the detection of regional distribution of alveolar ventilation and, thus, the quantification of local inhomogeneities in lung mechanics. By detecting recruitment and derecruitment, a positive end-expiratory pressure level at which tidal ventilation is relatively homogeneous in all lung regions can be defined. Additionally, different approaches to characterize the temporal local behaviour of lung tissue during ventilation have been proposed, which adds important information. Summary There is growing evidence that supports EIT usage as a bedside measure to individually optimize ventilator settings in critically ill patients in order to prevent ventilator-induced lung injury. A standardization of current approaches to analyse and interpret EIT data is required in order to facilitate the clinical implementation.
TL;DR: Patients treated with molecular adsorbent recirculating system (MARS) had improved serum levels of inflammatory mediators such as tumor necrosis factor alpha and interleukin-6, but this was not associated with improved survival.
Abstract: Purpose of reviewCirculatory abnormalities in cirrhosis include hyperdynamic circulation and cirrhotic cardiomyopathy. The extent of circulatory abnormalities is further exaggerated in acute-on-chronic liver failure (ACLF). The mechanism remains unclear and management also needs to be evaluated.Rece