Current opinion in critical care
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Curr Opin Crit Care · Aug 2015
ReviewUsing cardiac output monitoring to guide perioperative haemodynamic therapy.
The aim of this study was to review recent advances and evidence for the use of cardiac output monitors to guide perioperative haemodynamic therapy. ⋯ Perioperative GDT remains an exciting intervention to reduce significant morbidity following major surgery; however, it is not yet a proven standard of care. Further large pragmatic trials are required to demonstrate its effectiveness particularly in the era of enhanced recovery after surgery programmes.
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To summarize clinical evidence for intraoperative ventilation settings, which could protect against postoperative pulmonary complications (PPCs) in surgical patients with uninjured lungs. ⋯ The understanding on the protective roles of tidal volume and PEEP settings against PPCs has rapidly expanded. During intraoperative ventilation, low tidal volumes are protective, the protective role of high levels of PEEP is uncertain.
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Curr Opin Crit Care · Aug 2015
ReviewEpidemiology of the high-risk population: perioperative risk and mortality after surgery.
This review will provide an overview of actual data concerning perioperative risk. Furthermore, strategies to prevent, detect and treat perioperative complications will be discussed. ⋯ It is imperative to reliably identify patients at risk for postoperative complications and to implement strategies into clinical practice allowing for prevention, early detection and effective treatment of complications. By bundling best practice concepts in all phases of perioperative care, patient outcome will be effectively improved.
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In shock states, optimizing intravascular volume is crucial to promote an adequate oxygen delivery to the tissues. Our current practice in fluid management pivots on the Frank-Starling law of the heart, and the effects of fluids are measured according to the induced changes on stroke volume. The purpose of this review is to evaluate the boundaries of current macrohemodynamic approach to fluid administration, and to introduce the microcirculatory integration as a fundamental part of tissue perfusion monitoring. ⋯ Current approach to intravascular volume optimization is made from a macrohemodynamic perspective. However, several situations wherein macrocirculatory and microcirculatory coherence is lost have been described. Future clinical trials should explore the usefulness of integrating the microcirculatory evaluation in fluid optimization.
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To describe the harmful effects of intravenous fluids on kidney structure and function and summarize recent comparisons between different fluids and their effect on kidney outcome. ⋯ Being nephrotoxic, synthetic colloids should be avoided in patients with reduced renal reserve, such as in critically ill patients and in patients with preexisting renal dysfunction. Suggested adverse effects with chloride-rich solutions need confirmation from ongoing trials. Albumin solutions are well tolerated in patients with sepsis and/or liver failure and improve outcomes in the latter.