Critical care clinics
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Improving the course and outcome of patients with ARDS presents a considerable challenge. An important component of meeting this challenge is a more comprehensive understanding of the heterogeneous pathophysiology of ARDS and the biologic response of the individual patient. ⋯ By understanding the immune status of a given patient at a given point in the disease process, physicians can consider manipulating proinflammatory systems more rationally, such as the complement and chemokine cascades, or the anti-inflammatory arm of the immune system. Finally, a more refined molecular and genetic understanding of endogenous cytoprotective molecules and mechanisms, such as the heat shock response and HO-1, may provide further tools in the future armamentarium against ARDS.
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Critical care clinics · Jan 2002
ReviewVentilator-associated pneumonia. Prevention, diagnosis, and therapy.
Ventilator-associated pneumonia remains the nosocomial ICU infection of greatest concern. The authors have summarized the clinical trials that have assessed specific strategies to prevent VAP and the current controversies regarding the diagnosis and therapeutic approach to this condition. Improvements in care of patients who are at risk for or who have developed VAP will depend on the judicious application of this information for individual patients.
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Critical care clinics · Jan 2002
ReviewARDS and the multiple organ dysfunction syndrome. Common mechanisms of a common systemic process.
The multiple organ dysfunction syndrome is a common but poorly understood complication of critical illness. Its evolution reflects the interactions of an acute, life-threatening insult, the response of the host to that insult, and the therapeutic measures instituted to restore normal homeostasis. ⋯ Therapy, in the absence of a more sophisticated understanding of pathologic mechanism, is supportive. The growing recognition that iatrogenic factors contribute to the expression of MODS has highlighted the need for the clinician to be aware of the potential for harm inherent with every intervention.
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Acute respiratory distress syndrome is a common condition among the critically ill and is associated with high morbidity and mortality [table: see text] rates. Improved understanding of the underlying inflammatory pathogenetics has encouraged the search for strategies that, by modifying this immune response, can improve outcome for this group of patients. Some agents are obviously anti-inflammatory. ⋯ Rather, it is probable that an individual patient will require a combination of several agents or different agents at different times during the disease process (Table 1). Mortality rates from ARDS already are beginning to fall with improved nutritional and ventilatory support. Positive results from trials using immunomodulatory agents are being reported, and soon such agents will form part of the routine management of patients with ARDS, further improving the outlook for these patients.
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Critical care clinics · Jan 2002
ReviewCytopathic hypoxia. Is oxygen use impaired in sepsis as a result of an acquired intrinsic derangement in cellular respiration?
Several lines of evidence indicate that cellular energetics are deranged in sepsis, not by inadequate tissue perfusion but rather by impaired mitochondrial respiration; that is, organ dysfunction in sepsis may result from cytopathic hypoxia. If this concept is correct, the therapeutic implications are enormous. Efforts to improve outcome in septic patients by monitoring and manipulating cardiac output, systemic oxygen (DO2), and regional blood flow are doomed to failure. Instead, the focus should be on developing pharmacologic strategies (e.g., isoform-selective iNOS or PARP inhibitors) to restore normal mitochondrial function and cellular energetics.