Seminars in respiratory and critical care medicine
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Cardiac alterations may be defined as changes that lead to abnormal cardiac function. They include decrease in preload, increase in afterload, and depressed cardiac contractility. Cardiac dysfunction differs from cardiac failure: cardiac performance is altered, but this does not necessarily mean that the cardiovascular system is failing. ⋯ Only when there is an imbalance between oxygen demand and oxygen transport is correction of cardiac alterations required. But the truth is that no study supports the use of one treatment rather than another. Changes in respiratory settings or in respiratory mechanics induce changes in cardiac function and must then be considered in the strategy.
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Cardiovascular system failure is commonly faced by the intensivist. Heart failure can occur due to a host of predisposing cardiac disorders or as secondary effects of systemic illness. When the heart is unable to provide an adequate cardiac output to maintain adequate tissue perfusion, cardiogenic shock ensues. ⋯ Accurate and rapid identification of cardiogenic shock as a medical emergency, with expeditious implementation of appropriate therapy, can lead to improved clinical outcomes. In this review, we discuss optimal strategies for diagnosis and monitoring of cardiogenic shock. We discuss the diverse therapeutic strategies employed for cardiogenic shock, including pharmacological (e.g., vasoactive agents, fibrinolytic agents), mechanical (e.g., intraaortic balloon pumps, left ventricular assist devices, percutaneous coronary intervention [PCI]), and surgical approaches such as coronary artery bypass graft (CABG), valvular repair or replacement (e.g., for acute mitral regurgitation, ventricular septal rupture, or free wall rupture).
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The role of dysfunction of the gastrointestinal tract in the pathogenesis of multiple organ failure (MOF) complicating the course of critically ill patients has been suspected for more than 40 years. However, several hypotheses have been proposed and sometimes refuted to establish a link. This review summarizes the current knowledge on gastrointestinal physiology and recapitulates existing evidence on the link between gastrointestinal dysfunction and MOF. ⋯ It produces hormones with local and systemic effects, plays a major role in immunological function, and serves as a barrier against antigens within its lumen. Gastrointestinal dysfunction or gut failure is frequently encountered in critical care patients and is associated with bacterial translocation, which can lead to the development of sepsis, initiation of a cytokine-mediated systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), and death. The aim of this manuscript is to define gut failure, to review physiopathological mechanisms and clinical implications, and, finally, to suggest preventive measures.
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Central nervous system (CNS) failure represents a spectrum of disease ranging from mild neurological impairment that may have motor, sensory, visual, speech, cognitive manifestations, or a combination thereof, to comatose states and brain death. This article summarizes the common causes of CNS failure and analyzes the role of clinical, radiological, laboratory, and other ancillary testing in establishing the underlying diagnosis and assessing severity of CNS failure in each condition; we also comment on various treatment options for each of the causes of CNS failure.
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Semin Respir Crit Care Med · Oct 2011
ReviewThe microcirculation as a therapeutic target in the treatment of sepsis and shock.
Largely ignored throughout the history of clinical medicine, the microcirculation has recently been recognized at the bedside as the center of several pathophysiological processes. Normal microcirculatory function is critical for adequate tissue oxygenation and organ function, but it has a poorly understood and highly heterogeneous structure that is related to the diversity of functions that it accomplishes. The most important function of the microcirculation is the regulation and distribution of oxygen carrying red blood cells within the different organs. ⋯ The introduction of bedside techniques into clinical practice that allow the evaluation of the microcirculation has opened up a new field of functional hemodynamic monitoring, identified the microcirculatory failure as the most sensitive indicator of circulatory failure associated with adverse outcome, and has provided the promise of identifying new therapeutic targets. Clinical research has identified various conventional and new therapeutic approaches that are successful in modifying the microcirculation. Current research must determine whether some of these approaches are successful in improving the outcome of critically ill patients by recruiting the microcirculation.