Current opinion in critical care
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Curr Opin Crit Care · Feb 2004
ReviewUnderstanding and managing fluid balance in patients with acute lung injury.
Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) affect hundreds of thousands of people each year worldwide, resulting in a significant healthcare burden. Over the past four decades, much has been discovered regarding the pathophysiology of lung injury, yet little progress has been made in advancing effective treatment strategies. In this article, we discuss the current knowledge as to fluid balance in the pathophysiology of ALI/ARDS and the recent innovations that have been described related to manipulations of hydrostatic or oncotic pressure in this condition. ⋯ Manipulation of Starling forces in established ALI/ARDS produces significant physiologic benefit and may influence outcome. Future research should focus on determining a mortality benefit with this readily available intervention.
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Curr Opin Crit Care · Feb 2004
ReviewUnderstanding and implementing advances in ventilator capabilities.
To review the changes in mechanical ventilation technology over the past year and identify areas that provide a benefit. ⋯ Mechanical ventilation is ubiquitous to intensive care. Advances in ventilator technology are rapid, and clinicians must keep abreast of changes in ventilator performance and application.
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To review the medical literature on neuromuscular abnormalities acquired in the intensive care unit (ICU), particularly after mechanical ventilation, focusing on the most recent advances in this field. ⋯ Avoiding complete neuromuscular inactivity, using corticosteroids with greater discernment, and closely monitoring blood glucose levels might be worthwhile avenues for research in prevention of neuromuscular abnormalities acquired in the most severely ill ICU patients. Investigations of the severity of the respiratory neuromuscular involvement are also warranted.
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Community-acquired pneumonia remains a common and serious condition worldwide. Severe community-acquired pneumonia requiring ICU admission is a distinct entity with different pathogens, outcomes, and management. ⋯ These guidelines have developed prediction tools to direct clinicians in the management of community-acquired pneumonia, including when to admit a patient to the ICU and selecting appropriate investigations and antimicrobial therapy. The individual recommendations of these guidelines and the guidelines as a whole require further studies.
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Severe acute respiratory syndrome (SARS) is a new disease that caused large outbreaks in several countries in the first half of 2003, resulting in infection in more than 8000 people and more than 900 deaths. During that time, a large body of literature rapidly emerged describing the clinical disease, the etiologic viral agent, and management options. This paper reviews the current status of this knowledge base, with particular reference to the critically ill patient. ⋯ SARS is a predominantly respiratory illness, spread through droplets from respiratory secretions and possibly via a fecal-oral route. A small number of "super-spreaders" appear to have contributed to the rapid proliferation of the disease. Infection control precautions are an essential component of management. Approximately 20% of patients develop progressive pulmonary infiltrates and respiratory failure, and the mortality rate is as high as 10%. Treatment strategies with antiviral agents such as ribavirin have not clearly demonstrated a benefit, but high-dose corticosteroids appear to be beneficial in patients with progressive disease. The recent outbreaks highlighted the potential for this disease to overwhelm critical care resources, by the volume of patients and loss of healthcare workers to illness and quarantine.