Current opinion in critical care
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In the field of prediction of fluid responsiveness, the most recent studies have focused on validating new tests, on clarifying the limitations of older ones, and better defining their modalities. ⋯ Research in this field is still very active, such that several indices and tests of fluid responsiveness are now available. They may contribute to reduce excessive fluid balance by avoiding unnecessary fluid administration and, also, by ensuring safe fluid removal.
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Esophageal manometry has shown its usefulness to estimate transpulmonary pressure, that is lung stress, and the intensity of spontaneous effort in patients with acute respiratory distress syndrome. However, clinical uptake of esophageal manometry in ICU is still low. Thus, the purpose of review is to describe technical tips to adequately measure esophageal pressure at the bedside, and then update the most important clinical applications of esophageal manometry in ICU. ⋯ Esophageal manometry is not a complicated technique. There is a large potential to improve clinical outcome in patients with acute respiratory distress syndrome, acting as an early detector of risk of lung injury from mechanical ventilation and vigorous spontaneous effort.
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Microcirculatory alterations play a major role in the pathogenesis of shock. Monitoring tissue perfusion might be a relevant goal for shock resuscitation. The goal of this review was to revise the evidence supporting the monitoring of peripheral perfusion and microcirculation as goals of resuscitation. For this purpose, we mainly focused on skin perfusion and sublingual microcirculation. ⋯ Measurements of peripheral perfusion might be useful as goal of resuscitation. The results of the ANDROMEDA-SHOCK will clarify the role of skin perfusion as a guide for the treatment of shock. In contrast, the assessment of sublingual microcirculation mainly remains as a research tool.
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Curr Opin Crit Care · Jun 2018
Review Comparative StudyIn-hospital cardiac arrest: are we overlooking a key distinction?
To review the epidemiology, peri-arrest management, and research priorities related to in-hospital cardiac arrest (IHCA) and explore key distinctions between IHCA and out-of-hospital cardiac arrest (OHCA) as they pertain to the clinician and resuscitation scientist. ⋯ IHCA is a unique disease entity with an epidemiology and natural history that are distinct from OHCA. In both research and clinical practice, physicians should recognize these distinctions so as to advance the care of IHCA victims.
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Cardiac arrest mortality remains high, and the impact on outcome of most advanced life support interventions is unclear. The optimal method for managing the airway during cardiac arrest remains unknown. This review will summarize and critique recently published evidence comparing basic airway management with the use of more advanced airway interventions [insertion of supraglottic airway (SGA) devices and tracheal intubation]. ⋯ Most of the available evidence about airway management during cardiac arrest comes from observational studies. The best option for airway management is likely to be different for different rescuers, and at different time points of the resuscitation process. Thus, it is common for a single patient to receive multiple 'stepwise' airway interventions. The only reliable way to determine the optimal airway management strategy is to undertake properly designed, prospective, randomized trials. One randomized clinical trial has been published recently and two others have completed enrollment but have yet to be published.