Current opinion in critical care
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Curr Opin Crit Care · Jun 2020
ReviewOptimal ventilator settings after return of spontaneous circulation.
To describe current practice, recent advances in knowledge and future directions for research related to the post return of spontaneous circulation (ROSC) ventilatory management of cardiac arrest patients. ⋯ Current evidence supports the targeting of normal arterial O2 and CO2 tensions during mechanical ventilation following ROSC after cardiac arrest. Use of protective lung strategies during mechanical ventilation in resuscitated cardiac arrest patients is advocated. The potential therapeutic benefits of conservative O2 therapy, mild hypercapnia and the optimal ventilator settings to use post-ROSC period will be confirmed or refuted in clinical trials.
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Curr Opin Crit Care · Jun 2020
ReviewMonitoring coherence between the macro and microcirculation in septic shock.
Currently, the treatment of patients with shock is focused on the clinical symptoms of shock. In the early phase, this is usually limited to heart rate, blood pressure, lactate levels and urine output. However, as the ultimate goal of resuscitation is the improvement in microcirculatory perfusion the question is whether these currently used signs of shock and the improvement in these signs actually correspond to the changes in the microcirculation. ⋯ The improvement in macrohemodynamics during the resuscitation is not consistently followed by subsequent changes in the microcirculation. This may result in both over-resuscitation and under-resuscitation leading to increased morbidity and mortality. In this article the principles of coherence and the monitoring of the microcirculation are reviewed.
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Despite restoration of adequate systemic blood flow in patients with shock, single organs may remain hypoperfused. In this review, we summarize the results of a literature research on methods to monitor single organ perfusion in shock. We focused on methods to measure heart, brain, kidney, and/or visceral organ perfusion. Furthermore, only methods that can be used in real-time and at the bedside were included. ⋯ Physical examination techniques have a reasonable negative predictive value to exclude single organ hypoperfusion but are nonspecific to detect it. Technical methods to indirectly measure myocardial perfusion include ECG and echocardiography. Contrast-enhanced ultrasound can quantify myocardial perfusion but has so far only been used to detect regional myocardial hypoperfusion. Near-infrared spectroscopy and transcranial Doppler sonography can be used to assess cerebral perfusion and determine autoregulation thresholds of the brain. Both Doppler and contrast-enhanced ultrasound techniques are novel methods to evaluate renal and visceral organ perfusion. A key limitation of most techniques is the inability to determine adequacy of organ blood flow to meet the organs' metabolic demands.
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Curr Opin Crit Care · Jun 2020
ReviewExtracorporeal cardiopulmonary resuscitation for cardiac arrest.
Extracorporeal cardiopulmonary resuscitation (ECPR) is a contemporary resuscitation approach that employs veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This approach is increasingly used worldwide to mitigate the widespread hemodynamic and multiorgan dysfunction that accompanies cardiac arrest. ⋯ ECPR offers a promising mechanism to mitigate multiorgan injury and allow time for the institution of supportive interventions required to effectively treat cardiac arrest. More prospective data in the context of extensive prehospital and hospital collaboration is needed to promote its successful use.
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Severe sepsis with septic shock is the most common cause of death among critically ill patients. Mortality has decreased substantially over the last decade but recent data has shown that opportunities remain for the improvement of early and targeted therapy. This review discusses published data regarding the role of focused ultrasonography in septic shock resuscitation. ⋯ Severe sepsis with septic shock is an insidious disease process that continues to take lives. In more recent years, data have emerged suggesting the utility of bedside ultrasonography for early cardiovascular categorization, goal directed resuscitation, and appropriate cardiovascular support based on its changing phenotypes.