Current opinion in critical care
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Curr Opin Crit Care · Jun 2011
ReviewShould mechanical ventilation be guided by esophageal pressure measurements?
Despite the well recognized role of mechanical ventilation in lung injury, appropriate surrogate markers to guide titration of ventilator settings remain elusive. One would like to strike a balance between protecting aerated units from overdistension while recruiting unstable units, thereby reducing tissue damage associated with their cyclic recruitment and derecruitment. To do so requires some estimate of the topographical distribution of parenchymal stress and strain. ⋯ Notwithstanding its theoretical limitations, esophageal manometry has shown promise in PEEP titration and deserves further evaluation in a larger trial on patients with injured lungs.
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Curr Opin Crit Care · Jun 2011
ReviewTargeting the microcirculation in resuscitation of acutely unwell patients.
The ultimate goals of hemodynamic therapy in acutely unwell patients are to restore effective tissue perfusion and oxygen delivery to maintain cellular metabolism. Optimization of systemic hemodynamics may improve the time course of microcirculatory dysfunction and eventually the patient's outcome. However, relationships between systemic hemodynamics and microcirculatory changes during resuscitation are complex and underperfused microcirculation may persist, despite restored macrohemodynamics. Thus, targeting the microcirculation is a logical goal to obtain an adequate resuscitation. ⋯ Microcirculatory hemodynamics have to be restored as soon as possible during the early phase of the management of acutely unwell patients. Future trials should test whether microcirculation-guided strategy could better improve organ dysfunction than global hemodynamic-guided strategy. An optimal resuscitation has to restore the systematic hemodynamics and make sure of the quality of the microcirculation.
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The holy grail of circulatory monitoring is an accurate, continuous and relatively noninvasive means of assessing the adequacy of organ perfusion. This could be then advantageously used to direct therapeutic interventions to prevent both under-treatment and over-treatment and thus improve outcomes. However, in view of the heterogeneous response (adaptive or maladaptive) of different organs to various shock states, any monitor of perfusion adequacy cannot reflect every organ system, but should at least detect early deterioration in a 'canary' organ. Tissue oxygen tension reflects the balance between local oxygen supply and demand, and could thus be a potentially useful monitoring modality. This article examines the different technologies available and reviews the current literature regarding its utility as a monitor. ⋯ Monitoring of tissue oxygen tension may offer a potentially useful tool for clinical management though significant validation needs to be first performed to confirm its promise.
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Recent recognition of the importance of postresuscitation care has stimulated interest and new reports concerning therapies for postcardiac arrest myocardial dysfunction. Such cardiac dysfunction after successful resuscitation can be severe and even lethal; however, it is also transient emphasizing the importance of early supportive therapies. ⋯ Every community should be striving to provide more timely restoration of pulse and circulation, whereas every medical center receiving patients resuscitated from out-of-hospital cardiac arrest should be providing therapeutic hypothermia for both central nervous system and myocardial preservation. The ability and commitment to provide '24/7' early coronary angiography and percutaneous intervention for all resuscitated victims of sudden cardiac death with a likely cardiac cause for their arrest is also key.