Current opinion in critical care
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Although advances in critical care management and liver transplantation have improved survival in acute liver failure (ALF), mortality remains significant. An evidence base to support management has been lacking, due to the condition's rarity, severity and heterogeneity. The purpose of this review is to critically appraise the latest evidence, updating clinicians on the current understanding of the best management. ⋯ Traditional dogma in ALF management is questioned: transplant thresholds for acetaminophen overdose, steroid use in autoimmune ALF, routine antimicrobial prophylaxis, the coagulopathy of liver disease, the value of intracranial pressure monitoring and extracorporeal liver support.
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Curr Opin Crit Care · Apr 2015
ReviewLiver transplantation in the context of organ shortage: toward extension and restriction of indications considering recent clinical data and ethical framework.
The scarcity of liver grafts requires to optimize the results of transplantation. Extensions and alternatives of liver transplantation have to be regularly evaluated. ⋯ Before implementation of these potential changes into decisional algorithms for listing and organ allocation, their consequences, either for patient's individual benefit or for global transplant outcomes, should be closely evaluated using objective long-term end points and taking into account the ethical recommendations for organ transplantation.
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Curr Opin Crit Care · Apr 2015
ReviewBlood pressure management in acute intracerebral hemorrhage: current evidence and ongoing controversies.
Spontaneous intracerebral hemorrhage (ICH) is associated with high rates of morbidity and mortality. Although treatment options are limited, a potential acute medical intervention is blood pressure (BP) reduction. The review will summarize the current evidence and remaining knowledge gaps with respect to acute BP management in acute ICH. ⋯ Recent trials have shown that BP lowering (<140 mmHg systolic) is well tolerated and may improve functional outcomes. Ongoing trials will provide insight into the overall benefit of early aggressive BP reduction in acute ICH.
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Curr Opin Crit Care · Apr 2015
ReviewRecommendations for the use of multimodal monitoring in the neurointensive care unit.
Multimodal monitoring (MMM) is routinely applied in neurointensive care. Unfortunately, there is no robust evidence on which MMM-derived physiologic variables are the most clinically relevant, how and when they should be monitored, and whether MMM impacts outcome. The complexity is even higher because once the data are continuously collected, interpretation and integration of these complex physiologic events into targeted individualized care is still embryonic. ⋯ MMM allows comprehensive exploration of the complex pathophysiology of acute brain damage and, depending on the different configuration of the pathological condition we are treating, the application of targeted individualized care. Unfortunately, we still lack robust evidence on how to better integrate MMM-derived information at the bedside to improve patient management. Advanced informatics is promising and may provide us a supportive tool to interpret physiologic events and guide pathophysiological-based therapeutic decisions.
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Although detailed practice parameters have been developed to help guide physicians in brain death determination, guidelines based on these parameters widely vary. The recent case of Jahi McMath not only highlights social misconceptions but also serves as a call to action to decrease medical variability and confusion regarding brain death determination. This review discusses common sources of variations in brain death determination - we divide these sources into before, during, and after brain death declaration. ⋯ Diagnosing brain death is confusing because of numerous variations in practice, but this variation can be improved. Improved and standardized physician training can help create a formal certification process for examiners and help create uniformity in brain death determination. National standards will also help decrease variability of practice.