Current opinion in critical care
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Curr Opin Crit Care · Jun 2005
ReviewHow monitoring of the microcirculation may help us at the bedside.
Recent technologic developments have allowed the direct visualization of the microcirculation at the bedside. The present review explores how the monitoring of microcirculation can help in clinical practice. ⋯ Microcirculation plays an important role in the pathogenesis of shock and organ dysfunction, especially in sepsis. Monitoring microcirculation at the bedside may be used to assess severity of the disease and to predict outcome, but in the absence of sufficient data regarding the effects of therapeutic interventions it cannot yet be used to guide therapy, even though this approach is promising.
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Curr Opin Crit Care · Jun 2005
ReviewRegional carbon dioxide monitoring to assess the adequacy of tissue perfusion.
Tissue dysoxia is now widely regarded as the major factor leading to organ dysfunction in critically ill patients. Recent data suggests that early aggressive resuscitation of critically ill patients, which limits and/or reverses tissue dysoxia may prevent progression to organ dysfunction and improve outcome. The traditional clinical and laboratory markers used to assess tissue dysoxia are, however, insensitive and have numerous limitations. Regional carbon dioxide monitoring appears to be ideally suited to monitoring the adequacy of resuscitation. This review provides an update on this evolving technology. ⋯ Sublingual capnometry may be the ideal technology for guiding early goal directed therapy. This technology may be useful for monitoring tissue oxygenation, titrating therapeutic interventions, and as an end point for resuscitation in critically ill and injured patients.
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Despite a more widespread knowledge of basic cardiopulmonary resuscitation maneuvers in the community, the survival rate for patients with cardiac arrest has remained essentially unchanged in the past 30 years. Over the past few decades, many different compression-ventilation ratios have been studied in terms of best coronary and cerebral oxygen delivery, restoration of spontaneous circulation, and neurologic outcome. This article summarizes the recent evidence presented at the International Consensus on Resuscitation Science in January 2005. ⋯ The optimal compression-ventilation ratio is still unknown and the best tradeoff between oxygenation and organ perfusion during cardiopulmonary resuscitation is probably different for each patient and scenario. A discrepancy between what is recommended by the current guidelines and the 'real world' of cardiopulmonary resuscitation has resulted in a near flat survival rate from cardiac arrest in the past few years.
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Because the right side of the heart supplies blood to the pulmonary circulation, its integrity is required for both adequate respiratory and circulatory function. By reducing pulmonary perfusion, right-sided heart failure may compromise arterial oxygenation and left ventricular filling, and monitoring of right-sided heart function at the bedside in critically ill patients is fundamental. Two recent clinical commentaries have focused on the invaluable help provided by echocardiography for this purpose. ⋯ Monitoring of right-sided heart function is essential in a clinical setting associated with hemodynamic instability, such as severe sepsis or acute coronary artery obstruction, and also in that it is associated with increased pulmonary vascular resistance, as in massive pulmonary embolism or acute respiratory failure. Moreover, use of mechanical ventilation requires regular evaluation of its effects on the right side of the heart.