Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2016
ReviewBalance between Hyperinflammation and Immunosuppression in Sepsis.
Sepsis is a major cause of morbidity and mortality among hospitalized patients and the leading cause of death among patients admitted to intensive care units. The immune response in sepsis is characterized by the activation of both proinflammatory and anti-inflammatory pathways. ⋯ Given the high burden of morbidity and mortality associated with sepsis, there is an increasing interest in immunomodulatory therapies targeted at improving outcomes in sepsis. This review will summarize current understanding about the balance between hyperinflammation and immunosuppression in sepsis and discuss the role of potential therapies to modulate these responses.
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Semin Respir Crit Care Med · Feb 2016
ReviewEarly Warning/Track-and-Trigger Systems to Detect Deterioration and Improve Outcomes in Hospitalized Patients.
As a global effort toward improving patient safety, a specific area of focus has been the early recognition and rapid intervention in deteriorating ward patients. This focus on "failure to rescue" has led to the construction of early warning/track-and-trigger systems. ⋯ Additionally, the strengths and weaknesses of the various systems and their evaluation in the literature are emphasized. Despite the limitations of the current literature, the potential benefit of these early warning/track-and-trigger systems to improve patient outcomes remains significant.
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Semin Respir Crit Care Med · Feb 2016
ReviewWho Should Be at the Bedside 24/7: Doctors, Families, Nurses?
Critical illness does not keep to regular, daytime business hours; we must provide high-quality care and support for intensive care unit (ICU) patients 24 hours per day, 7 days per week. Whether this mandates the presence of similar numbers and types of personnel throughout all hours of the day, however, has been the subject of much debate and substantial research. In this article, we review the available literature on the consequences of having three groups of care providers at a patient's bedside overnight: physicians, visitors, and nurses. ⋯ Uncertainties include whether outcomes are better when each nurse is assigned only one patient (or, more generally, the optimal patient:nurse ratio), who these nurses should be (e.g., registered nurses vs. other personnel), and what their roles should entail (e.g., managing ventilators). As such, we cannot yet identify the optimal overnight nurse staffing strategy. What is clear is that the critical care community needs more and better data to further define these aspects of the relationship between ICU structure and ICU outcomes.
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Semin Respir Crit Care Med · Feb 2016
ReviewWhat Is the Evidence for Harm of Neuromuscular Blockade and Corticosteroid Use in the Intensive Care Unit?
Neuromuscular blocking agents and corticosteroids are widely used in medicine and in particular in the intensive care unit (ICU). Neuromuscular blockade is commonly used to ease tracheal intubation, to optimize mechanical ventilation and oxygenation in acute respiratory disorders such as status asthmaticus and acute respiratory distress syndrome (ARDS), to prevent shivering during therapeutic hypothermia, and also in patients with elevated intracranial pressure. In the ICU, patients with sepsis, ARDS, community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, severe asthma, or trauma may receive corticosteroids. ⋯ Both superinfections and ICU-acquired paresis are more likely when high doses of fluorinated corticosteroids are combined with prolonged treatment with a long-acting non-depolarizing neuromuscular blocker. Modern ICU practices favor lower dose of corticosteroids and very short course of short-acting curare for the management of sepsis or ARDS. Recent trials provided no evidence for increased risk of secondary infections or critical illness neuromyopathy in patients with sepsis or ARDS with the use of corticosteroids or neuromuscular blockers.
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Survivors of critical illness often experience long-lasting impairments in mental, cognitive, and physical functioning. Acute stress reactions and delusional memories appear to play an important role in psychological morbidity following critical illness, and few interventions exist to address these symptoms. This review elucidates acute psychological stressors experienced by the critically ill. ⋯ Memory may play a role in the genesis of subsequent psychological trauma. Traumatic memories may begin forming even before the patient arrives in the ICU and during their state of unconsciousness in the ICU. Hence, practical interventions for redirecting patients' thoughts, such as positive suggestion techniques and actively involving patients in the treatment process as early as possible, are worthy of further investigation.