Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2015
ReviewAwake or Sedated: Trends in the Evaluation and Management of Agitation in the Intensive Care Unit.
Critically ill intensive care unit (ICU) patients often require sedation to tolerate life-saving interventions such as mechanical ventilation. Pain, anxiety, and delirium all contribute to patient distress and agitation which can interfere with ICU medical care if not addressed and treated appropriately. Sedation practices to treat pain, anxiety, and delirium that deviate from established practice guidelines affect mechanical ventilation duration, ICU and hospital length of stay, functional impairment, and mortality. ⋯ This review will focus on changes in sedation practice in the ICU over the past three decades. With the implementation of validated sedation assessment scales, a multidisciplinary treatment model, and development of daily awakening protocols, no or minimal sedation can be achieved in the majority of ICU patients. Frequent, careful consideration of the environmental stimuli that contribute to patient discomfort and agitation and judicious use of sedative medications individualized to each patient are important in achieving this goal.
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Semin Respir Crit Care Med · Dec 2015
ReviewControversies in the Management of Severe ARDS: Optimal Ventilator Management and Use of Rescue Therapies.
Groundbreaking research into the pathophysiology of the adult acute respiratory distress syndrome (ARDS) and the prevention of ventilator-induced lung injury has led to dramatic improvements in survival. Investigations over the last two decades have revolved around the development of rescue therapies that can be used for patients with severe ARDS and refractory hypoxemia. To date, the techniques of using high levels of positive end-expiratory pressure (PEEP), prompt institution of neuromuscular blockade, and early prolonged prone positioning have been shown to reduce mortality in patients with severe ARDS. ⋯ A major randomized controlled trial conducted during this period showed a significant mortality benefit for patients with severe ARDS who were referred to a center with ECMO capabilities. The routine use of inhaled nitric oxide for patients with severe ARDS has not been shown to lead to more than a transient and limited improvement in oxygenation, which may hinder its use as a sole rescue therapy. Finally, recent studies have found that the routine use of high-frequency oscillatory ventilation in severe ARDS does not result in decreased mortality, although the technique has not been specifically investigated as rescue therapy for severe refractory hypoxemia.
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Semin Respir Crit Care Med · Dec 2015
ReviewPersonalized Critical Care Medicine: How Far Away Are We?
Personalized medicine has typically referred to the use of genomics in clinical care. However, the concept more broadly refers to recognizing the heterogeneity of each individual patient, particularly their unique risk factors for developing disease or having poor outcomes, and using this to inform treatment decisions. Pharmacogenomics was perhaps the first major clinical application that came out of the Human Genome Project, but its translation to the critical care arena has been limited by numerous factors. ⋯ While our understanding of the pathogenesis of critical illness has progressed significantly, the clinical utility of genetic markers remains limited. Novel methods are reaching closer to clinically applicable platforms, both for use in clinical trials and in direct patient care. Although we are not yet living in an era of personalized and precise medical care in the intensive care unit, the future is promising.
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Semin Respir Crit Care Med · Oct 2015
ReviewHistoplasmosis: Up-to-Date Evidence-Based Approach to Diagnosis and Management.
Histoplasmosis is the most common endemic mycosis in the North America, Central America, and many countries of South America and also occurs in China, India, Southeast Asia, Africa, Australia, and Europe. Clinical syndromes are not specific and histoplasmosis often is overlooked in the evaluation of patients with community-acquired pneumonia, chronic cavitary pneumonia resembling tuberculosis or anaerobic infection, granulomatous inflammatory diseases such as sarcoidosis or Crohn disease, and malignancy. ⋯ Treatment is appropriate in most patients with acute pulmonary disease but rarely in those with other pulmonary or mediastinal manifestations. The preferred agents include liposomal amphotericin B for more severe cases and itraconazole for milder cases and "step-down" therapy following response to amphotericin B.