Critical care clinics
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Critical care clinics · Jul 2018
ReviewDevice Management and Flow Optimization on Left Ventricular Assist Device Support.
The authors discuss principles of continuous flow left ventricular assist device (LVAD) operation, basic differences between the axial and centrifugal flow designs and hemodynamic performance, normal LVAD physiology, and device interaction with the heart. Systematic interpretation of LVAD parameters and recognition of abnormal patterns of flow and pulsatility on the device interrogation are necessary for clinical assessment of the patient. Optimization of pump flow using LVAD parameters and echocardiographic and hemodynamics guidance are reviewed.
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Cardiogenic shock is a clinical syndrome characterized by low cardiac output and sustained tissue hypoperfusion resulting in end-organ dysfunction and death. In-hospital mortality rates range from 50% to 60%. ⋯ Aggressive, hemodynamically guided medical management with careful monitoring of clinical and hemodynamic parameters with timely use of appropriate mechanical circulatory support devices is often necessary. As treatment options evolve, prospective randomized controlled trials are needed to define best practices that define superior clinical outcomes.
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Critical care clinics · Jul 2018
ReviewAvoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization.
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. ⋯ Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Sepsis rapid response teams are being incorporated into hospitals around the world. Based on the concept of the medical emergency team, the sepsis rapid response team consists of a specifically trained team of health care providers educated in the early recognition, diagnosis, and treatment of patients at risk of having or who have sepsis. Using hospital-wide initiatives consisting of multidisciplinary education, training, and specific resource utilization, such teams have been found to improve patient outcomes.
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Critical care clinics · Apr 2018
ReviewA Decade of Difficult Airway Response Team: Lessons Learned from a Hospital-Wide Difficult Airway Response Team Program.
A decade ago the Difficult Airway Response Team (DART) program was created at The Johns Hopkins Hospital as a multidisciplinary effort to address airway-related adverse events in the nonoperative setting. Root cause analysis of prior events indicated that a major factor in adverse patient outcomes was lack of a systematic approach for responding to difficult airway patients in an emergency. The DART program encompasses operational, safety, and educational initiatives and has responded to approximately 1000 events since its initiation, with no resultant adult airway-related adverse events or morbidity. This article provides lessons learned and recommendations for initiating a DART program.