Current opinion in critical care
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Curr Opin Crit Care · Oct 2012
ReviewWhat is the niche for extracorporeal membrane oxygenation in severe acute respiratory distress syndrome?
This article reviews the results of case series and trials which evaluated venovenous extracorporeal membrane oxygenation (VV-ECMO) for severe respiratory failure. Potential indications of the technique in this setting are discussed. ⋯ Before widespread diffusion of VV-ECMO for severe ARDS, new trials should test the efficacy of early initiation of the technique with tight control of mechanical ventilation in the control group, initiation of ECMO prior to transportation to ECMO centers, and the use of ECMO in every patient randomly assigned to receive it.
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As numbers of patients who survive a critical illness increase, often within a context of comorbidities and acquired physical, mental or cognitive sequelae [postintensive care syndrome (PICS)], identifying effective recovery and rehabilitation strategies is paramount. In this review, we discuss recent studies that inform our developing understanding for improving the recovery trajectory for survivors of a critical illness during the postintensive care and posthospital periods. ⋯ Innovative rehabilitation and recovery strategies during the postintensive care and posthospital periods are now being published. Further research with larger sample sizes, well-documented usual care and intervention arms and in different critical illness cohorts is required to demonstrate the optimal approaches for screening, implementation, outcome assessment and follow-up periods for rehabilitation interventions in the postintensive care phase of a patient's recovery.
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Lung transplantation (LTx) has become established as a standard intervention for patients suffering from end-stage lung disease. Transplant recipients are, however, predisposed to numerous unique complications arising from the surgery, transplant immunology and the lifelong medication. Clinicians working in intensive care are increasingly likely to be exposed to these patients and it is therefore important to have a working knowledge of the common complications. ⋯ This review highlights the most important complications after LTx and gives an update on diagnostic algorithms and treatment challenges for patients following LTx.
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ICU-acquired weakness (ICUAW) is now recognized as a major complication of critical illness. There is no doubt that ICUAW is prevalent - some might argue ubiquitous - after critical illness, but its true role, the interaction with preexisting nerve and muscle lesions as well as its contribution to long-term functional disability, remains to be elucidated. ⋯ Variable contributions of structural and functional changes likely contribute to both early and late myopathy and neuropathy, although the specifics of the temporality of both processes, and the influence patient comorbidities, age, and nature of the ICU insult have on them, remain to be determined.
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Curr Opin Crit Care · Oct 2012
ReviewDoes resistance in severe infections caused by methicillin-resistant Staphylococcus aureus give you the 'creeps'?
The clinical implications of reduced vancomycin susceptibility amongst methicillin-resistant Staphylococcus aureus (MRSA) are controversial, and crossresistance to daptomycin amongst such strains has been reported. As a consequence of 'MIC creep', higher trough levels were recommended for serious infections. This review focusses on the new data published in the past 18 months that pertain to these issues. ⋯ Continued monitoring of patients on aggressive vancomycin dosing schedules is advised. Unless alternative dosing strategies prove otherwise efficacious, an alternative antibiotic should be considered for severe MRSA infections with vancomycin MICs greater than 1 mg/l. The utility of vancomycin may be waning but will depend on the prevalence of resistant MRSA phenotypes in a specific ICU.