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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To appraise the basic and more advanced methods available for hemodynamic monitoring, and describe the definitions and criteria for the use of hemodynamic variables. ⋯ Determination of accurate diagnosis and prognosis for patients suspected of circulatory shock is essential for optimal decision-making. Numerous techniques are available, and each has its specific indications and value.
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Curr Opin Crit Care · Jun 2020
ReviewIndividualized blood pressure targets during postcardiac arrest intensive care.
To discuss recent findings relevant to optimizing blood pressure targets in adult, postcardiac arrest (PCA) patients and whether to tailor these based on specific patient, cardiac arrest or treatment characteristics. ⋯ Current evidence suggests targeting a MAP of at least 65-75 mmHg in PCA patients. Future studies should focus on whether certain patient groups could benefit from higher and dynamic MAP targets.
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We will highlight the role of ventriculoarterial coupling in the pathophysiology of sepsis and how to assess it. ⋯ Ventriculoarterial coupling is quantified as the ratio of Ea to Ees. The efficiency of the cardiovascular function is optimal when Ea/Ees is near one. When the hydraulic load of the arterial system is excessive either from increased vasomotor tone, decreased LV contractility or both, Ea/Ees becomes greater than 1 (i.e. ventriculoarterial decoupling), and cardiac efficiency decreases leading to heart failure, loss of volume responsiveness, and if sustained, increased mortality. Noninvasive echocardiographic techniques when linked with arterial pressure monitoring allow for the bedside estimates of both Ea and Ees. Studies using this approach have documented the key role ventriculoarterial coupling has defining initial cardiovascular state, response to therapy and outcome from critical illness. Sequential monitoring of ventriculoarterial coupling at the bedside offers a unique opportunity to assess relevant cardiovascular determinants in septic patients requiring resuscitation.
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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.