Current opinion in critical care
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Curr Opin Crit Care · Apr 2009
ReviewCorrection of coagulopathy in warfarin associated cerebral hemorrhage.
Warfarin is the most commonly used oral anticoagulant. Intracranial hemorrhage is the most serious complication of anticoagulation and the anticoagulant effect of warfarin has to be urgently reversed in this situation. Traditional methods of reversal of the anticoagulant effect of warfarin involving the use of vitamin K and fresh frozen plasma are slow and relatively ineffective and there is a need for alternative treatment approaches. ⋯ There is a need for well designed randomized clinical trials aimed at evaluating the efficacy of these agents in improving the outcome of patients with anticoagulant associated intracranial hemorrhage.
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Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS), the pathophysiologic implications of elevated intraabdominal pressure (IAP), have detrimental effects on all organ systems and are associated with significant morbidity and mortality. Within the past few years, the diagnosis and management of these syndromes have evolved tremendously. ⋯ Liberal IAP measurement in the presence of known risk factors combined with implementation of an evolving and comprehensive resuscitation strategy have resulted in significant improvements in both short and long-term outcome for patients who develop IAH/ACS. All clinicians should be aware of the risk factors that predict development of IAH/ACS, the appropriate measurement of IAP, and the current resuscitation options for managing these highly morbid syndromes.
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To discuss the risk factors and underlying illnesses that play a role in the pathophysiology of stress ulcer, and to evaluate the evidence pertaining to stress ulcer-related bleeding prophylaxis in critically ill patients. ⋯ Routine prophylaxis against stress ulcers in the ICU is not well justified by current evidence. Patients at risk of stress ulcer-related bleeding are most likely to benefit from prophylaxis. Thus, healthcare professionals should continue to evaluate risk and assess the need for stress ulcer-related prophylaxis.
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Curr Opin Crit Care · Apr 2009
ReviewWhich H is the most important in triple-H therapy for cerebral vasospasm?
To summarize the recent literature of the hemodynamic management of subarachnoid hemorrhage and cerebral vasospasm, also designated as 'triple-H' therapy, and discuss each component of this management approach individually. ⋯ There remains a paucity of information regarding the efficacy and safety of triple-H therapy. The complexity in exploring this topic derives not only from the interdependence of the different components of triple-H therapy but also by the limitation in the assessment of hemodynamic variables. However, there is some emerging physiologic data suggesting that normovolemic hypertension may be the component most likely to increase cerebral blood flow after subarachnoid hemorrhage. In contrast, hypervolemic hemodilution is associated with increased complications and might also lower the hemoglobin to excessively low levels.
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Continuous electroencephalography (cEEG) is being used more frequently in intensive care units to detect epileptic activity and ischemia. This review analyzes clinical applications and limitations of cEEG as a routine neuromonitoring tool. ⋯ cEEG should be considered as an integral part of multimodality monitoring of the injured brain, particularly in patients at risk for nonconvulsive seizure or ischemia. Automated alarms may help establish cEEG monitoring as an integral part of brain monitoring. All neurological ICUs that routinely care for patients with refractory status epilepticus should have the capability to perform cEEG monitoring. Further research determining the impact on outcome and making EEG monitoring more user friendly may help move this technique out of the subspecialized ICU setting into the general ICU environment. In the future, it may be possible to use specific EEG parameters as endpoints for therapeutic interventions.