Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Oct 2019
ReviewPain and Delirium in Critical Illness: An Exploration of Key 2018 SCCM PADIS Guideline Evidence Gaps.
Managing pain and delirium are crucial to patients, families, and caregivers in intensive care units. The Society of Critical Care Medicine 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep disruption (PADIS) guidelines reviewed literature until October 2015 and made its recommendations for critically-ill adults. This chapter addresses evidence gaps, identified during the guideline process, most relevant to clinicians, adds newer evidence published after the PADIS 2018 guidelines were produced, describes hindsight-driven PADIS process or content-related gaps, and reflects on how these considerations may help inform future research investigations and new guideline efforts.
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Semin Respir Crit Care Med · Oct 2019
ReviewThe Long and Winding Road to Personalized Glycemic Control in the Intensive Care Unit.
In the critically ill adult, dysglycemia is a marker of disease severity and is associated with worse clinical outcomes. Close monitoring of glucose and use of insulin in critically ill patients have been done for more than 2 decades, but the appropriate target glycemic range in critically ill patients remains controversial. Physiological stress response, levels of inflammatory cytokines, nutritional intake, and level of mobility affect glycemic control, and a more personalized approach to patients with dysglycemia is warranted in critically ill intensive care unit (ICU) patients. We discuss the pathophysiology and downstream effects of altered glycemic response in critical illness, management of glycemic control in the ICU, and future strategies toward personalization of critical care glycemic management.
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Semin Respir Crit Care Med · Oct 2019
ReviewReconsidering Nutritional Support in Critically Ill Patients.
Provision of nutrition is universally considered a key element of supportive care in the intensive care unit (ICU). Despite this, there is a relative dearth of high-quality data, and where available, results are often conflicting. ⋯ In the modern ICU era, where the goal of critical care has shifted from mere survival to surviving and living well, non-continuous modes of feeding may have advantages related to fewer feeding interruptions, ICU mobilization, optimizing protein synthesis and autophagy, as well as restoring gastrointestinal physiology and the circadian rhythm. More research is desperately required to provide a framework in order to guide best nutrition practices for clinicians at the bedside.
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Semin Respir Crit Care Med · Oct 2019
ReviewControversies Surrounding Renal Replacement Therapy in the Critically Ill Patient.
Acute kidney injury (AKI) commonly occurs in the intensive care unit and is associated with significant morbidity and mortality. Patients with AKI often require initiation of dialysis to control electrolytes, metabolic abnormalities, and volume status. This review will discuss controversies in renal replacement therapy (RRT), including timing of dialysis initiation, dialysis modality and dose, nonrenal indications for dialysis, and the patient population best suited for RRT therapy.
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Semin Respir Crit Care Med · Oct 2019
ReviewSleep in the Intensive Care Unit: Strategies for Improvement.
Sleep in the intensive care unit (ICU) is considered to be subjectively poor, highly fragmented, and sometimes referred to as "atypical." Although sleep is felt to be crucial for patient recovery, little is known about the association of sleep with physiologic function among critically ill patients, or those with clinically important outcomes in the ICU. Research involving ICU-based sleep disturbance is challenging due to the lack of objective, practical, reliable, and scalable methods to measure sleep and the multifactorial etiologies of its disruption. Despite these challenges, research into sleep-promoting techniques is growing and has demonstrated a variety of causes leading to ICU-related sleep loss, thereby motivating multifaceted intervention efforts. Through a focused review of (1) sleep measurement in the ICU; (2) outcomes related to poor sleep in the ICU; and (3) ICU-based sleep promotion efforts including environmental, nonpharmacological, and pharmacological interventions, this paper examines research regarding sleep in the ICU and highlights the need for future investigation into this complex and dynamic field.