AACN advanced critical care
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Sedation management in the mechanically ventilated critically ill patient is a topic of continuing interest in the critical care literature. The wide variety of clinical practices described in the literature with regard to sedation management has limited the implementation of evidence-based practice guidelines. ⋯ We provide a summary of the literature on key aspects of sedation in clinical practice. Evidence-based recommendations are provided for clinicians involved in the management of sedation in mechanically ventilated patients.
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Numerous pressure modes are currently available on ventilators. The application of microprocessor technology has resulted in sophisticated mode options that are very responsive to patient-initiated efforts, yet little is known about how to use the modes or their effect on patient outcomes. This article describes a wide variety of pressure modes including traditional modes such as pressure support and pressure-controlled ventilation in addition to less traditional new modes such as airway pressure release ventilation, biphasic positive airway pressure, Pressure Augmentation (Bear 1000, Viasys Healthcare, Yorba Linda, California), Volume Support (Maquet, Bridgewater, New Jersey), Pressure Regulated Volume Control (Maquet, Bridgewater, New Jersey), Volume Ventilation Plus (Puritan Bennett, Boulder, Colorado), Adaptive Support Ventilation (Hamilton Medical, Switzerland), and Proportional Assist Ventilation (Dräger Medical, Richmond Hill, Ontario, Canada). The "good, the bad, and the ugly" issues surrounding the application, evaluation, and outcomes of the modes are discussed.
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Review Case Reports
Treating distress at the end of life: the principle of double effect.
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Septic shock continues to be one of the leading causes of death in the intensive care unit today. The confluence of many factors contributes to the deterioration of patients' condition in septic shock. Increased levels of nitric oxide, in part, mediate the cardiovascular effects of septic shock. ⋯ Endogenous vasopressin and angiotensin II act synergistically to preserve and restore blood pressure levels. Decreased circulating vasopressin contributes to adrenal insufficiency via hypothalamic-pituitary-adrenal axis suppression and increased catecholamine resistance to vasopressors. Exogenous vasopressin supplementation in physiologic doses has been shown to improve blood pressure levels and decrease vasopressor needs in patients with septic shock.