Critical care clinics
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Evidence provides weak support for the routine use of vasopressors in cardiac arrest where the quality of CPR and post arrest care are unknown and the drug is given late. In these pragmatic settings, epinephrine improves clinical outcomes, but does so at the price of increasing the proportion of patients surviving with poor neurologic function at 30 days. In settings where the quality of CPR and post arrest care are optimized the additive effect of epinephrine on clinical outcomes is not significantly different. Well designed efficacy trials are needed where routine cardiac arrest care is optimized.
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Cardiac arrest results from a broad range of etiologies that can be broadly grouped as sudden and asphyxial. Animal studies point to differences in injury pathways invoked in the heart and brain that drive injury and outcome after these different forms of cardiac arrest. ⋯ Existing clinical data reveal significant heterogeneity in the utility of presently employed resuscitation and postresuscitation strategies based on etiology. The development of future neuroprotective and cardioprotective therapies should also take etiology into consideration to optimize the chances for successful translation.
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Critical care clinics · Oct 2020
ReviewHow to Start an Enhanced Recovery After Surgery Cardiac Program.
In this review the authors introduce a practical approach to guide the initiation of an enhanced recovery after surgery (ERAS) cardiac surgery program. The first step in implementation is organizing a dedicated multidisciplinary ERAS cardiac team composed of representatives from nursing, surgery, anesthesiology, and other relevant allied health groups. Identifying a program coordinator or navigator who will have responsibilities for developing and implementing educational initiatives, troubleshooting, monitoring progress and setbacks, and data collection is also vital for success. An institution-specific protocol is then developed by leveraging national guidelines and local expertise.
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Critical care clinics · Oct 2020
ReviewPreoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers.
Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. ⋯ Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.
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Prolonged intubation and mechanical ventilation following cardiac surgery have been associated with increased hospital and intensive care unit length of stays; higher health care costs; and morbidity resulting from atelectasis, intrapulmonary shunting, and pneumonia. Early extubation was developed as a strategy in the 1990s to reduce the high-dose opiate regimes and long ventilator times. Early extubation is a key component of the enhanced recovery pathway following cardiac surgery and enables early mobilization and early return to a normal diet. The plan to extubate should start as soon as the patient is scheduled for cardiac surgery and continue throughout the perioperative period.