Critical care nursing quarterly
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Aggressive fluid resuscitation is the mainstay therapy in modern sepsis management. Its efficacy was demonstrated in the landmark study by Emmanuel Rivers in 2001. However, more recent evidence largely shows that a positive fluid balance increases mortality in critically ill patients with sepsis. This article examines the theoretical benefits of fluid resuscitation and physiological responses to it that may negatively affect patients' outcome.
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Starling's forces are fundamental to our understanding of physiology. Based on his findings, hydrostatic pressure and oncotic pressure are crucial factors in the movement of intravascular and extravascular fluid. However, new literatures on endothelial glycocalyx, a layer of protective glycoprotein within the vasculature that was first discovered in the 1980s, are reshaping our standard models of Starling's forces. This article examines the nature of the endothelial glycocalyx and why understanding it may change the way we resuscitate patients with sepsis.
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Hypotensive episodes are common among patients in the intensive care unit and can lead to multiorgan failure if uncontrolled. Fluid administration and continuous infusion of vasoactive agents are frequently used for management of hypotension; however, both therapies may be associated with adverse effects including pulmonary edema and tissue necrosis. ⋯ These agents may not only be used when first-line agents are unavailable due to shortages, but they may also aid in reducing the cumulative dose of other vasoactive agents used. The purpose of this review was to discuss strategies for the safe and effective use of methylene blue, pseudoephedrine, and midodrine for the treatment of hypotension in the critically ill.
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Normal saline is the crystalloid of choice for fluid resuscitation with its utility born out of the cholera epidemic of 1832. However, its ubiquitous usage is being challenged because of a growing body of evidence suggesting that a large volume infusion of normal saline does in fact have deleterious effects on multiple body systems. Careful considerations should be given to the physiological effects of using large amounts of normal saline as one would with another pharmacological agents.
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As the United States population ages, patients in intensive care units (ICUs) bring with them the challenges of an aging population. One challenge is the different types of confusions seen in the geriatric patient. ⋯ The purpose of this article was to differentiate between the 3 most common confusions among older adults--delirium, dementia, and depression. In addition, this article discusses confusion seen postoperatively and post-ICU stay.