Journal of critical care
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Journal of critical care · Jun 2009
ReviewLow-molecular-weight heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review.
The study aimed to systematically review the effect of low-molecular-weight heparin (LMWH) thromboprophylaxis in medical-surgical critically ill patients in the intensive care unit. ⋯ Low-molecular-weight heparin may be effective for thromboprophylaxis in medical-surgical critically ill patients, but no trials have compared LMWH against an alternative active strategy; thus, LMWH cannot be recommended routinely. Trials testing LMWH thromboprophylaxis are required, which examine patient-important end points such as the incidence and clinical consequences of VTE, bleeding, heparin-induced thrombocytopenia, and mortality.
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Journal of critical care · Jun 2009
ReviewThe intensive care unit work environment: current challenges and recommendations for the future.
The need for critical care services has grown substantially in the last decade in most of the G8 nations. This increasing demand has accentuated an already existing shortage of trained critical care professionals. Recent studies argue that difficulty in recruiting an appropriate workforce relates to a shortage of graduating professionals and unhealthy work environments in which critical care professionals must work. ⋯ This narrative review summarizes existing literature and experiences about the key work environment challenges reported within the critical care context and suggests best practices-implemented in hospitals or suggested by professional associations-which can be an initial step in enhancing patient care and professional recruitment and retention in our intensive care units, with particular emphasis on the recruitment and retention of an appropriately trained and satisfied workforce. The experiences are categorized for the physical, emotional, and professional environments. A case study is appended to enhance understanding of the magnitude and some of the proposed remedies of these experiences.
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Journal of critical care · Jun 2009
ReviewManagement of venous thromboembolism in the intensive care unit.
Venous thromboembolism, manifested as either deep venous thrombosis or pulmonary embolism (PE), is a major cause of morbidity and mortality in patients admitted to the intensive care unit. Clinically, PE may present as massive thromboembolism associated with cardiogenic shock or may be asymptomatic, as may occur with anatomically small emboli without hemodynamic or respiratory compromise. The management of venous thromboembolism in the critically ill patient can be exceedingly complex. ⋯ Prevention of recurrent PE is accomplished with anticoagulation and/or placement of an inferior vena cava filter. Definitive therapy involves thrombolysis and surgical or catheter embolectomy. Fluid and vasoactive therapy with norepinephrine may be indicated for refractory hypotension in patients with massive PE.
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Journal of critical care · Mar 2009
ReviewPhysiology and biology of neuromuscular transmission in health and disease.
The introduction of powerful and contemporary research techniques has allowed for an increasingly detailed understanding of neuromuscular transmission. The classic model of nerve signaling to muscle using acetylcholine has been well described. ⋯ In this review, new concepts relative to neuromuscular transmission in health and disease are discussed, including a detailed discussion of acetylcholine and acetylcholine receptor physiology. Recent elucidations of the pathophysiologic responses to neuromuscular injury and its clinical implications are also detailed.
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Sugammadex is the first selective relaxant binding agent which was originally designed to reverse the steroidal NMB drug rocuronium. The results of recent studies demonstrate that sugammadex is effective for reversal of rocuronium and vecuronium-induced neuromuscular block without apparent side-effects. This is in contrast to the currently available cholinesterase inhibitors used to reverse neuromuscular block and which are even ineffective against profound neuromuscular block and have a number of undesirable side-effects. ⋯ Once sugammadex becomes commercially available, anesthesiologists will be capable of maintaining the desired depth of neuromuscular block at any time, thereby assuring optimal surgical conditions. The mechanism by which sugammadex encapsulates rocuronium and vecuronium appears to be superior to currently used neuromuscular block reversal strategies in terms of speed, efficacy and side effects. In this article, clinical studies of sugammadex are discussed.