Seminars in respiratory and critical care medicine
-
A substantial number of patients with liver failure are admitted to the intensive care unit; thus a thorough understanding of the prevention and treatment of complications in such patients is imperative. The management of liver failure is demanding and often involves the combined efforts of many specialists. ⋯ The initial assessment and management of acute liver failure are reviewed with an emphasis on the prevention and treatment of brain edema in the pretransplant setting. The current treatment of complications resulting from decompensated chronic liver disease such as portal hypertensive bleeding; infection, renal failure, and hepatic encephalopathy are then discussed.
-
Shock is one of the most frequent situations encountered in the intensive care unit (ICU). Important new concepts have emerged for shock management in recent years. The concept of early goal-directed therapy has evolved from the basic management concepts for septic shock delivered in a structured fashion. ⋯ Prediction of responsiveness to fluid administration is a key component of the management of shock, as is assessing cardiovascular performance. The intensive care physician has several options to evaluate and treat shock. Further research should yield additional important advances.
-
Semin Respir Crit Care Med · Jun 2006
ReviewDelirium and cognitive dysfunction in the intensive care unit.
Delirium remains a non recognized, but highly prevalent, form of organ dysfunction in the intensive care unit (ICU). Intensive care physicians have begun to benefit from elucidation of risk factors for delirium in the ICU, some of which are modifiable, whereas others are not. In the last 5 years, a new tool for use in detecting delirium among critically ill patients has been adapted, validated, and found objectively reliable for use at the bedside by nonpsychiatrists. ⋯ Although prevention and treatment options exist, little data guide current pharmacological approaches to delirium, and nonpharmacological approaches have yet to be fully adopted by ICUs. Ongoing trials will address some of these limitations, but large cohort studies within the ICU are needed to further clarify risk factors and to identify targets to modify the occurrence and course of delirium. Furthermore, consideration of a continuum may better elucidate the true magnitude of acute brain dysfunction in the ICU.
-
Hematologic disorders are frequently encountered in the intensive care unit. Thrombocytopenia, often defined as a platelet count below 100,000/microL, is common in critically ill patients and may be associated with adverse outcomes. A systematic evaluation of clinical and laboratory findings is necessary to ascertain the cause of the thrombocytopenia and to determine the correct therapy. ⋯ Advances in understanding the pathogenesis of DIC have generated new treatment approaches, such as the use of recombinant activated protein C. Recombinant factor VIIa (rFVIIa) is a novel drug approved for use in patients with congenital hemophilia and inhibitors. Although its use as a hemostatic agent is currently being evaluated in several off-label scenarios, including trauma, intracerebral hemorrhage, and liver disease, there are limited data to guide therapy in these conditions.
-
Diseases of the airway are common and make up a significant proportion of the respiratory physician's workload. The major contributors to this situation, such as asthma, chronic obstructive pulmonary disease (COPD), and chronic cough, all result from airway inflammation and often have an overlapping clinical picture, which in some instances makes accurate clinical diagnosis difficult. Asthma is a condition characterized by variable airflow obstruction, airway hyper-responsiveness, and airway inflammation, which is usually eosinophilic. ⋯ COPD has generally been considered to be a neutrophilic disease, in contrast to asthma. However, there is increasing evidence that a significant subgroup exists consisting of patients with stable COPD who have chronic airway eosinophilia with a more steroid-responsive disease. This article covers the role of eosinophils in the airway disorders asthma, COPD, and eosinophilic bronchitis.