Current opinion in critical care
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Curr Opin Crit Care · Aug 2014
ReviewPulmonary complications in patients receiving a solid-organ transplant.
Major improvements in perioperative care and immunobiology have not abated the risk for severe pulmonary complications after solid-organ transplantation. The aim of this study is to update information on infectious and noninfectious pulmonary complications after solid-organ transplantation, addressing epidemiology, risk factors, diagnostic workup, and management. ⋯ Pulmonary complications after solid-organ transplantation, and particularly infections, are able to compromise the extremely good results of the transplant procedures. Solid-organ transplantation recipients challenge the ICU physician with unique aspects of their post-transplant course, adding, in an already critical patient, the immunosuppressed state and the quality of the functional recovery of the graft.
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Early acute respiratory distress syndrome (ARDS) is characterized by protein-rich inflammatory lung edema often associated with a hydrostatic component. Mechanical ventilation with positive intrathoracic pressure further induces salt and water retention, while impairing the pathways designed for edema clearance. In this framework, we will review the recent findings on fluid strategy and edema clearance in ARDS. ⋯ Lung edema is likely the single pathogenic factor more relevant for ARDS severity and outcome. Fluid overload must be avoided. Several monitoring techniques are available to reach this target. No specific studies are available to recommend a given fluid composition in ARDS. In our opinion, the general recommendations for fluid composition suggested for severe sepsis and septic shock should be applied to ARDS that may be considered an organ-confined sepsis.
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Curr Opin Crit Care · Aug 2014
ReviewPrevention of renal dysfunction in postoperative elderly patients.
To describe the effect of ageing on kidney function and to summarize the benefits of advocated measures to prevent perioperative acute kidney injury (AKI) in elderly patients. ⋯ The future increase in elderly patients being exposed to surgery calls for improved perioperative management to prevent collaterally increased AKI. Although pharmacological therapies aiming to protect the kidneys from harm are under evaluation, hemodynamic optimization and avoidance of nephrotoxic drugs, including HES and hyperchloremic solutions, are critical for the elderly perioperative patient.
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Curr Opin Crit Care · Aug 2014
ReviewCoagulation and transfusion in the postoperative bleeding patient.
Bleeding can be minimal, severe, life-threatening, or organ-threatening. Depending on the compensatory capacity of the patient, most bleeding events going beyond 20% blood volume may represent an emergency as well as a risk factor for anemia, transfusion, coagulopathy, and tissue hypoperfusion. All these factors are independent predictors for survival in postoperative critical care and are drivers for resource use and costs. ⋯ Individualized coagulation management guided by viscoelastic tests and restrictive transfusion behavior are encouraged in clinical practice of critical care. Potential fields of research are multifold, for example, thromboembolic adverse effects of hemostatic interventions in the isochronic postoperative acute-phase response, transfusion restrictions by increasing postoperative tolerance to anemia and erythropoiesis, and implementation of guidelines and institutional algorithms.