Current opinion in critical care
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To discuss the perioperative monitoring tools and targets for haemodynamic optimization and to assess the influence of goal-directed therapy (GDT) on organ function, complications and outcome in different categories of surgical patients. ⋯ GDT provides a number of benefits in major surgery. Based on adequate monitoring, the goal-directed algorithms facilitate early detection of pathophysiological changes and influence the perioperative haemodynamic therapy that can improve the clinical outcome. The perioperative GDT should be early, adequate and individualized for every patient.
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Tissue hypoxia is a key trigger for organ dysfunction. The maintenance of adequate tissue oxygenation is therefore of particular importance during major surgery. In this review, we discuss the physiological basis and the rationale underlying the recent concepts of perioperative oxygen therapy. ⋯ Adequacy of oxygen delivery to tissue oxygen metabolic demand is essential during the perioperative period. The benefit of perioperative oxygen therapy is rather optimizing the DO2 than increasing inspired oxygen. Improving DO2 has been demonstrated in the perioperative period to reduce both morbidity and mortality. Adaptation of DO2 to O2 consumption using specific goals seems promising.
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Intravenous fluids are widely administered in the ICU with the intention of preventing or ameliorating acute kidney injury (AKI). This review focuses on recent studies examining fluid administration and renal function in critical illness to critically examine conventional justifications for fluid administration. ⋯ Adequate volume resuscitation remains a cornerstone to the emergent treatment of critical illness. However, continued fluid administration and positive fluid balances have not been shown to improve renal outcomes and may worsen overall prognosis in AKI. Concerns about renal dysfunction should not deter clinicians from adopting more restrictive approaches to fluid administration.
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Although longstanding practice in trauma care has been to provide immediate, aggressive intravenous fluid resuscitation to injured patients with presumed internal hemorrhage, recent experimental and clinical data suggest a more discriminating approach that first considers concurrent head injury, hemodynamic stability, and the presence of potentially uncontrollable hemorrhage (e.g., deep truncal injury) versus a controllable source (e.g., distal extremity wound). ⋯ Future research efforts in trauma should focus on the timing and rate of infusions as well as the concept of infusing alternative intravenous resuscitative fluids such as hemoglobin-based oxygen carriers (HBOCs) and the use of hemostatic agents and special blood products.
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To examine the role of fluid therapy in the pathogenesis of severe sepsis and septic shock. The type, composition, titration, management strategies and complications of fluid administration will be examined in respect to outcomes. ⋯ Although this pathogenesis is evolving, early titrated fluid administration modulates inflammation, improves microvascular perfusion, impacts organ function and outcome. Fluid administration has limited impact on tissue perfusion during the later stages of sepsis and excess fluid is deleterious to outcome. The type of fluid solution does not seem to influence these observations.