Seminars in respiratory and critical care medicine
-
Semin Respir Crit Care Med · Oct 2019
ReviewTranslational Research in Intensive Care Unit: Novel Approaches for Drug Development and Personalized Medicine.
The major clinical presentations seen by critical care physicians are sepsis and acute respiratory distress syndrome (ARDS), both of which are heterogeneous clinical syndromes rather than specific diagnoses. The current diagnostic criteria provide little insight into the mechanisms underlying these heterogeneous syndromes and minimal progress has been made with regard to the development of therapies, despite many large randomized controlled trials being undertaken. This review outlines the advances made in improved characterization of critically-ill patients, using ARDS as an exemplar, and highlights the need for this improved patient characterization to be coupled with mechanistic science to develop therapies that target specific pathomechanisms.
-
Semin Respir Crit Care Med · Oct 2019
ReviewPatient-Centered Outcomes in Critical Illness: Will My Patient Be Functionally and Cognitively Intact?
Survival in the intensive care unit (ICU) has steadily increased over the past several decades; millions of patients now survive a critical illness every year. ICU survivors are at a significantly increased risk of impairments in physical function, cognitive function, and mental health. ⋯ Landmark studies concerning treatment preferences have demonstrated that patients value functional and cognitive outcomes over mortality. In this chapter, we discuss the determinants of functional and cognitive outcomes post critical illness to address the question, "Will my ICU patient be functionally and cognitively intact?"
-
The overarching goals of early sepsis management include early recognition, appropriate antibiotic therapy and source control, maintenance of hemodynamic stability, and supportive care of organ dysfunction. Despite increasing awareness of the global burden of sepsis, and general agreement on the goals of management, there is ongoing controversy regarding the implementation of specific treatment strategies to optimize patient outcomes. ⋯ These include optimal timing of antibiotics in patients with potential sepsis, the role of glucocorticoids in septic shock, vitamin C as a novel therapy for sepsis, the ideal intravenous fluid for resuscitation, and the optimal balance of fluid resuscitation and vasopressor administration in septic shock. For each of these topics, we review relevant literature, discuss areas of controversy, and present our current approach to management.
-
Semin Respir Crit Care Med · Oct 2019
ReviewEmerging Ethical Challenges in Critical Care for the 21st Century: A Case-Based Discussion.
Ethical challenges for doctors and other health care professionals have existed since the practice of medicine began. Many of the oldest challenges live on to this day, such as who has more authority to make key decisions (autonomy vs. paternalism) and what are the boundaries of life at the beginning and at the end. Two powerful driving forces are new technologies and an ever-changing culture and society. ⋯ In other areas, the concept of patient autonomy has been used to request life-prolonging therapies, once thought "futile." New technologies for procreation have necessitated new ethical challenges as well. In this paper, we will use a series of cases, based on experiences from our hospital ethics committee, that occurred over the course of several years and illustrate ethical challenges which are either new to us or not new but growing in frequency due to technological or societal changes. Each one of these topics is complex and worthy of its own large review but for this overview, we will briefly discuss the key points of each dilemma.
-
Semin Respir Crit Care Med · Oct 2019
ReviewInnovative ICU Solutions to Prevent and Reduce Delirium and Post-Intensive Care Unit Syndrome.
Delirium, the most common form of acute brain dysfunction affecting up to 80% of intensive care unit (ICU) patients, has been shown to predict long-term cognitive impairment, one of the domains in "Post-ICU Syndrome" (PICS). The ICU environment affects several potentially modifiable risk factors for delirium, such as disorientation and disruption, of the sleep-wake cycle. ⋯ Implementation of corresponding solutions is challenging considering the significant medical and technical demands of ICUs. This article discusses innovative concepts and promising approaches in ICU design that may be used to prevent stress and to support the healing process of patients, potentially limiting the impact of delirium and PICS.