Current opinion in critical care
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Curr Opin Crit Care · Aug 2018
ReviewNutritional support in patients with extracorporeal life support and ventricular assist devices.
Extracorporeal life support (ECLS) including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) provide mechanical pulmonary and circulatory support, respectively, in patients with acute pulmonary or cardiovascular failure. This review discusses recently published data regarding specific topics of nutritional support in patients with ECLS and VAD. ⋯ Despite the exponential use of ECLS and VAD over the last decade, the role of nutrition on clinical outcome in this patient population remains an important but yet underinvestigated field.
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Temporary circulatory support (TCS) with short-term mechanical circulatory support (MCS) devices is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of current devices, their indications and management, and discusses results of recent case series and trials. ⋯ TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the respective place of different MCS devices in cardiogenic shock treatment strategies.
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There has been a recent shift in the focus of providing nutrition support to critically ill adults towards enhancing recovery and promoting survivorship. With this has come an evaluation of our current approaches to nutrition support, which includes whether continuous feeding is optimal, particularly for reducing muscle wasting, but also for managing blood glucose levels and feeding intolerance and at the organizational level. This review will discuss the pros and cons of using intermittent and continuous feeding relating to several aspects of the management of critically ill adults. ⋯ Although there are limited studies investigating the safety and efficacy of an intermittent rather than continuous feeding regimen in critically ill adults, there are several theoretical advantages. Further studies should investigate these and in the meantime, feeding regimens should be devised based on individual patient factors.
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Curr Opin Crit Care · Aug 2018
ReviewCritical care echocardiography and outcomes in the critically ill.
Critical care echocardiography offers a comprehensive assessment of cardiac anatomy and function performed by the intensivist at point of care. This has resulted in widespread use of critical care echocardiography in ICUs leading to the question if this increased usage has resulted in improved patient outcomes. ⋯ Recent studies have evaluated the role of critical care echocardiography in the ICU with an emphasis on establishing accurate diagnosis and measurement of haemodynamic variables. There are no prospective randomized controlled trials that have examined the effect of critical care echocardiography on patient outcomes SUMMARY: Although the effect of critical care echocardiography on patient outcomes has not yet been established, its value as a diagnostic tool has been well demonstrated. We can only assume that its diagnostic capability leads to an improvement in patient outcomes.
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To provide an overview of recent findings concerning refeeding syndrome (RFS) among critically ill patients and recommendations for daily practice. ⋯ RFS is a potentially life-threatening condition induced by initiation of feeding after a period of starvation. Although a uniform definition is lacking, most definitions comprise a complex constellation of laboratory markers (i.e. hypophosphatemia, hypokalemia, hypomagnesemia) or clinical symptoms, including cardiac and pulmonary failure. Recent studies show that low caloric intake results in lower mortality rates in critically ill RFS patients compared with RFS patients on full nutritional support. Therefore, standard monitoring of RFS-markers (especially serum phosphate) and caloric restriction when RFS is diagnosed should be considered. Furthermore, standard therapy with thiamin and electrolyte supplementation is essential.