Critical care medicine
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Critical care medicine · Feb 2013
Review Meta AnalysisToothbrushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia.
Oral care may decrease ventilator-associated pneumonia in the ICU. The objective of this review was to summarize and critically appraise randomized trials in mechanically ventilated patients in the ICU testing the effect of oral care strategies involving toothbrushing on ventilator-associated pneumonia. ⋯ In intubated, mechanically ventilated critically ill patients, toothbrushing did not significantly reduce the risk of ventilator-associated pneumonia overall. Toothbrushing has no effect on mortality or length of stay. Electric and manual toothbrushing seem to have similar effects. More research is needed on this aspect of oral care to evaluate its potential to decrease ventilator-associated pneumonia.
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Critical care medicine · Feb 2013
ReviewOxygen therapy in critical illness: precise control of arterial oxygenation and permissive hypoxemia.
The management of hypoxemia in critically ill patients is challenging. Whilst the harms of tissue hypoxia are well recognized, the possibility of harm from excess oxygen administration, or other interventions targeted at mitigating hypoxemia, may be inadequately appreciated. The benefits of attempting to fully reverse arterial hypoxemia may be outweighed by the harms associated with high concentrations of supplemental oxygen and invasive mechanical ventilation strategies. We propose two novel related strategies for the management of hypoxemia in critically ill patients. First, we describe precise control of arterial oxygenation involving the specific targeting of arterial partial pressure of oxygen or arterial hemoglobin oxygen saturation to individualized target values, with the avoidance of significant variation from these levels. The aim of precise control of arterial oxygenation is to avoid the harms associated with inadvertent hyperoxia or hypoxia through careful and precise control of arterial oxygen levels. Secondly, we describe permissive hypoxemia: the acceptance of levels of arterial oxygenation lower than is conventionally tolerated in patients. The aim of permissive hypoxemia is to minimize the possible harms caused by restoration of normoxemia while avoiding tissue hypoxia. This review sets out to discuss the strengths and limitations of precise control of arterial oxygenation and permissive hypoxemia as candidate management strategies in hypoxemic critically ill patients. ⋯ Implementation of precise control of arterial oxygenation may avoid the harms associated with excessive and inadequate oxygenation. However, at present there is no direct evidence to support the immediate implementation of permissive hypoxemia and a comprehensive evaluation of its value in critically ill patients should be a high research priority.
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Critical care medicine · Feb 2013
ReviewRole of the venous return in critical illness and shock: part II-shock and mechanical ventilation.
To provide a conceptual and clinical review of the physiology of the venous system as it is related to cardiac function in health and disease. ⋯ An improved understanding of the role of the venous system in pathophysiologic conditions will allow intensivists to better appreciate the complex circulatory physiology of shock and related therapies. This should enable improved hemodynamic management of this disorder.