Current opinion in critical care
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Acute gastrointestinal bleeding is a frequent emergency situation, whose incidence will likely rise as a result of the increasing use of direct anticoagulants and of the medical progresses resulting in longer life expectancy with underlying comorbidities. Updated guidelines and improvements in the diagnostic and therapeutic tools are now available and will likely improve the management of massive gastrointestinal bleeding in the near future. ⋯ The implementation of multidisciplinary diagnostic and therapeutic algorithms for the management of massive bleeding requires a close collaboration between emergency physicians, intensivists, endoscopists, radiologists and surgeons. A sequential strategy involving each of these specialists is desirable for a successful management of acute and massive gastrointestinal bleeding.
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Although nonoperative management (NOM) is the safest option in most patients with liver and splenic injuries or splenic injuries, some cases still need operative intervention. The aim of this review is to address the most recent literature and the evidence it provides for indications and timing of operative treatment for liver and spleen injuries. ⋯ Unstable patients with suspected ongoing bleeding from liver and spleen injuries or spleen injuries with inadequate effect of resuscitation should undergo immediate explorative laparotomy.More RCTs are needed to further determine the role of angiographic embolization and who can be safely be treated nonoperatively and who needs surgical intervention.
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Curr Opin Crit Care · Dec 2017
ReviewEarly haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy.
The aim of this study was to discuss the recent developments in trauma-induced coagulopathy and the evolvement of goal-directed therapy. ⋯ Trauma resuscitation should focus on early goal-directed therapy with use of viscoelastic haemostatic assays while initially applying a ratio 1:1:1 driven transfusion therapy (with red blood cells, plasma and platelets) in order to sustain normal haemostasis and control further bleeding.
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Traumatic injuries are a major cause of mortality worldwide. Damage control resuscitation or balanced transfusion of plasma, platelets, and red blood cells for the management of exsanguinating hemorrhage after trauma has become the standard of care. We review the literature regarding the use of alternatives to achieve the desired 1 : 1:1 ratio as availability of plasma and platelets can be problematic in some environments. ⋯ In the face of hemorrhagic shock from traumatic injury, resuscitation should be initiated with 1 : 1 : 1 transfusion of plasma, platelets, and red blood cells with limited to no use of crystalloids. Availability of plasma and platelets is limited in some environments. In these situations, the use of low titer type O whole blood, thawed or liquid plasma, cold stored platelets or reconstituted FDP can be used as substitutes to achieve optimal transfusion ratios. The hemostatic properties of CSPs may be superior to room temperature platelets.
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Curr Opin Crit Care · Dec 2017
ReviewAcute kidney injury and electrolyte disorders in the critically ill patient with cancer.
Patients with cancer increasingly make up a significant proportion of patients receiving care in the intensive care unit (ICU). Acute kidney injury and cancer-associated electrolyte disorders are encountered in many of these patients and can significantly impact both short-term and long-term outcomes. ⋯ This review outlines key knowledge areas for critical care physicians and nephrologists caring for patients with cancer and associated kidney issues such as acute kidney injury and electrolyte disorders. Specifically, understanding kidney-specific effects of new chemotherapeutic approaches is outlined, and provides an up-to-date compendium of these effects.