Intensive care medicine
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Abstract
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Intensive care medicine · Jun 2018
LetterDo change of care and rehabilitation for patients with mechanical ventilation increase chances of return to work? : Discussion on organ support therapy in the intensive care unit and return to work: a nationwide, register-based cohort study.
Abstract
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Intensive care medicine · Jun 2018
ReviewDiagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper.
This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors. ⋯ The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.
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Intensive care medicine · Jun 2018
ReviewPerioperative myocardial injury and the contribution of hypotension.
Mortality in the month following surgery is about 1000 times greater than anesthesia-related intraoperative mortality, and myocardial injury appears to be the leading cause. There is currently no known safe prophylaxis for postoperative myocardial injury, but there are strong associations among hypotension and myocardial injury, renal injury, and death. During surgery, the harm threshold is a mean arterial pressure of about 65 mmHg. ⋯ The threshold triggering injury on surgical wards remains unclear but may be in between. Much of the association between hypotension and serious complications surely results from residual confounding, but sparse randomized data suggest that at least some harm can be prevented by intervening to limit hypotension. Reducing hypotension may therefore improve perioperative outcomes.