Current opinion in critical care
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Bleeding remains a challenge in surgery. A unique drug, recombinant factor VIIa, causes clotting exclusively at bleeding sites. Recombinant factor VIIa has recently been introduced to surgery where current evidence, consisting mostly of case reports, suggest remarkable safety and efficacy. The first randomized controlled trials are only now being published with less remarkable results. This manuscript summarizes the current evidence. ⋯ Current evidence does not yet support recombinant factor VIIa as standard of care in surgery. However, the evidence indicates that recombinant factor VIIa should be used in intracerebral hemorrhage and massive perioperative or traumatic bleeding refractory to conventional therapies. For now, the bedside decision to use recombinant factor VIIa remains a matter of surgical judgment.
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Perioperative nutrition has been extensively studied, but numerous questions remain unanswered. This review focuses on new developments in nutrient delivery in the immediate perioperative period. Issues specifically addressed include which patients are most likely to benefit from perioperative nutritional supplementation, and the optimal route, timing, and quantity of nutrient delivery. ⋯ The particulars of nutritional support for perioperative and critically ill patients remain controversial. Recent studies addressing specific issues in this diverse discipline perhaps raise more questions than are answered. However, each new contribution to the literature brings us closer to an understanding of optimal nutritional management in the metabolically stressed patient.
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This article summarizes the current state of damage-control laparotomy as practiced in trauma surgery. Since the first description of deliberately abbreviated laparotomy 20 years ago, damage-control laparotomy has been widely applied. The purpose of this review is to discuss current concepts in damage-control laparotomy in trauma and general surgery patients. ⋯ Application of abbreviated laparotomy has been widely applied in the trauma population. Breaking the pathophysiologic cycle of hypothermia, coagulopathy, and acidosis with this approach has improved survivorship in this critically injured group of patients. The extension of the abbreviated laparotomy concept has also been described in the general surgery population, and raises the possibility of extending this concept to broader surgical fields.
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The conventional view in severe sepsis or septic shock is that most of the lactate that accumulates in the circulation is due to cellular hypoxia and the onset of anaerobic glycolysis. A number of papers have suggested that lactate formation during sepsis is not due to hypoxia. I discuss this hypothesis and outline the recent advances in the understanding of lactate metabolism in shock. ⋯ There is increasing evidence that sepsis is accompanied by a hypermetabolic state, with enhanced glycolysis and hyperlactataemia. This should not be rigorously interpreted as an indication of hypoxia. It now appears, at least in the hyperkinetic state, that increased lactate production and concentration as a result of hypoxia are often the exception rather than the rule.
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Statins are effective lipid-lowering agents used extensively in medical practice. This review summarizes the evidence for statin treatment of cardiovascular patients in the intensive care unit and briefly discusses the role of statins in prevention and treatment of sepsis as a potential future application of statins in critical care. ⋯ Statin therapy should be continued in intensive-care patients in whom statin therapy is warranted due to underlying cardiovascular disease or significant risk thereof. In acute coronary syndromes, statin therapy should be initiated within 24-96 h regardless of pretreatment cholesterol levels. Patients undergoing vascular surgery should receive peri-operative statin therapy. Placebo-controlled clinical trials are required to consolidate the experimental and observational evidence for prevention and treatment of sepsis.