Current opinion in critical care
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Curr Opin Crit Care · Dec 2004
ReviewA single-pass batch dialysis system: an ideal dialysis method for the patient in intensive care with acute renal failure.
Conventional intermittent hemodialysis and continuous veno-venous hemofiltration are the opposite poles of current treatment modalities for patients with acute renal failure in the intensive care unit. Because both intermittent and continuous renal replacement techniques have several disadvantages, alternative treatment strategies have been developed. This review summarizes relevant information on these new hybrid techniques, and special attention is paid to the use of a single-pass batch dialysis system in the intensive care unit. ⋯ Sustained low-efficiency dialysis is increasingly being used as renal replacement therapy in critically ill patients in the intensive care unit. It combines several advantages of both intermittent and continuous techniques. The procedural simplicity, particularly if single-pass batch dialysis is used, makes it an ideal treatment for patients with renal failure in the intensive care unit.
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The trauma population is at increased risk of venous thromboembolic disease, a potentially preventable cause of mortality and morbidity. Although the association between trauma and venous thromboembolism has been recognized for more than a century, there is still great variability in the clinical practices with respect to prophylaxis. This thorough review of recent literature aims to clarify the incidence and risk factors for deep venous thrombosis and pulmonary embolism after trauma, review options and recommendations for detection of deep venous thrombosis and pulmonary embolism, and give evidence-based recommendations for prophylaxis. Special attention is paid to patients with spinal cord injury, patients with head injury, and pediatric trauma patients. ⋯ Venous thromboembolism remains an area of active clinical research focusing on evolving diagnostic techniques, newer methods of chemical and mechanical prophylaxis, and improved understanding of the etiologic factors of posttraumatic venous thromboembolism. These efforts will undoubtedly decrease the posttraumatic morbidity and mortality associated with venous thromboembolism.
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Curr Opin Crit Care · Dec 2004
ReviewThe immunoneuroendocrine axis in critical illness: beneficial adaptation or neuroendocrine exhaustion?
Over the last years, endocrinology has been incorporated in critical care medicine, and acknowledgment of the complex neuro-endocrine adaption of critical illness has led to new insights and major breakthroughs in clarifying pathophysiological mechanisms and the targeting of therapeutic strategies. This review focuses on the important role of the hypothalamic-pituitary-adrenal (HPA) axis during critical illness and the occurrence of neuroendocrine failure. ⋯ The endocrine system is highly interrelated with the immune and neural systems, the neuroimmunoendocrine axis is subject to clear biphasic changes in the acute and chronic phases of critical illness, most likely reflecting a beneficial adaptation. These neuroendocrine dynamics should be considered when assessing the neuroendocrine system, in particular the HPA axis.
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Curr Opin Crit Care · Dec 2004
ReviewInformed consent of incapable (ICU) patients in Europe: existing laws and the EU Directive.
The new European legislation on good clinical practice in the conduct of clinical trials on drugs has raised serious concern that potentially lifesaving studies cannot be carried out in critically ill patients in Europe anymore after May 2004. The requirement of nominating a legal representative for obtaining informed consent before inclusion will deprive current and future patients of participation in research. The new legislation does not differentiate between patients who are incompetent because of a psychiatric illness or dementia and patients who are incapacitated owing to an emergency situation. All those patients may be enrolled in a clinical trial only after informed consent has been granted by a legal representative. ⋯ Many groundbreaking therapies will not be scientifically evaluated anymore, and thus beneficial treatments in fatal diseases will be prevented. The European legislation is asked to adapt the Directive to promote research in critically ill patients.
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Curr Opin Crit Care · Dec 2004
ReviewVentilator strategies for posttraumatic acute respiratory distress syndrome: airway pressure release ventilation and the role of spontaneous breathing in critically ill patients.
Patients who experience severe trauma are at increased risk for the development of acute lung injury and acute respiratory distress syndrome. The management strategies used to treat respiratory failure in this patient population should be comprehensive. Current trends in the management of acute lung injury and acute respiratory distress syndrome consist of maintaining acceptable gas exchange while limiting ventilator-associated lung injury. ⋯ Airway pressure release ventilation is a mode of mechanical ventilation that maintains lung volume to limit intra tidal recruitment /derecruitment and improves gas exchange while limiting over distension. Clinical and experimental data demonstrate improvements in arterial oxygenation, ventilation-perfusion matching (less shunt and dead space ventilation), cardiac output, oxygen delivery, and lower airway pressures during airway pressure release ventilation. Mechanical ventilation with airway pressure release ventilation permits spontaneous breathing throughout the entire respiratory cycle, improves patient comfort, reduces the use of sedation, and may reduce ventilator days.