Current opinion in critical care
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Cardiogenic shock is a life-threatening emergency that occurs frequently with acute coronary syndromes. If rapid myocardial reperfusion following acute myocardial infarction is not obtained, either with thrombolytics or by revascularization, cardiogenic shock frequently develops and the mortality rate is high. This review summarizes recent advances in the pathophysiology, incidence and treatment of cardiogenic shock. Particular attention is given to pharmacologic advances. ⋯ Emerging pharmacological interventions designed to counteract the underlying proinflammatory pathophysiologic mechanisms may, in combination with early revascularization, result in improved patient outcomes, but there is no magic bullet on the horizon. Attention to the timeliness of transport and treatment of patients with a focus on revascularization is required for cardiogenic shock patients.
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Curr Opin Crit Care · Oct 2006
ReviewMicrocirculatory disorders in sepsis and transplantation: therapy with natural coagulatory inhibitors antithrombin and activated protein C.
Modern technologies allow visualization of microcirculatory disorders. This review describes how the coagulatory inhibitors antithrombin and activated protein C (APC) can improve microcirculation in sepsis and transplantation. ⋯ Microcirculatory dysfunction plays a key role in the development of organ dysfunction in septic patients and after solid organ transplantation. The exogenous application of coagulatory inhibitors may provide a new important strategy for prevention and treatment of microcirculatory disorders. This mode of action may be the reason why coagulatory inhibitors could improve mortality in septic patients without directly influencing inflammatory mediator concentrations.
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The large variability in clinical practice plus the increasing awareness that certain processes of care are associated with improved medical outcomes has led to the development of clinical practice guidelines in serious infection. The evolution of guidelines and their impact on delivery of care in severe infection is reviewed. ⋯ The change bundle approach to performance improvement (guidelines-based) is the key to change in practice. The Surviving Sepsis Campaign/Institute of Healthcare Improvement sepsis change bundles are an excellent example of progress along these lines.
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Patients requiring prolonged mechanical ventilation consume a disproportionate amount of healthcare resources and clinician time. Measurement and knowledge of their outcomes will guide efforts to improve their care. ⋯ The long-term outcomes of patients requiring prolonged mechanical ventilation are poor for the majority of patients, especially the elderly. Continued research is needed to identify the highest-risk patients, and to improve outcomes during hospitalization and in the immediate postdischarge period.