Current opinion in critical care
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Curr Opin Crit Care · Dec 2019
ReviewReview of massive transfusion protocols in the injured, bleeding patient.
Massive haemorrhage is a significant cause of mortality and morbidity in a variety of clinical settings, although most research has been related to trauma patients. Military studies from recent conflicts found that higher ratios of plasma to red blood cells (RBCs) were associated with increased survival in injured soldiers, and subsequent trials in civilian populations showed similar decreased mortality. Over the last decade, massive transfusion protocols (MTPs) have become an important component in the treatment of the massively bleeding patient. This review is intended to summarize the more recent findings and trends in massive transfusion. ⋯ The absence of a universal definition of massive bleeding or massive transfusion, heterogeneity in patients suffering from massive bleeding, and the difficulty in predicting which patients will require a massive transfusion all contribute to the difficulty of studying massive transfusion. However, there is evidence that higher plasma : RBC ratios correlate with improved survival, and that adjuncts to transfusion play a key role. Furthermore, recent validations of massive haemorrhage scoring systems should allow more consistent and appropriate triggering of massive transfusions.
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The aging surgical population constitutes a unique challenge to clinicians across the spectrum of care. Frailty is a valuable tool for preoperative risk stratification and may guide targeted interventions, such as prehabilitation. The aim of this review is to revise the recent literature on the role of frailty and prehabilitation to optimize geriatric patients undergoing surgery. ⋯ Frailty is a valuable risk stratification tool that better captures the state of augmented vulnerability of older adults. Frail patients benefit from targeted interventions, such as multimodal prehabilitation. Thus, the implementation of nationwide geriatric surgery standards can address ongoing challenges in performing surgery on older, frail patients.
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Curr Opin Crit Care · Dec 2019
ReviewSudden unresponsive patient with normal vital signs: what is going on?
To summarize the differential diagnosis and diagnostic approach of sudden unresponsiveness with normal vital signs in various settings, including the ICU. ⋯ Sudden unresponsiveness with normal vital signs should trigger immediate and focused diagnostic evaluation to find or exclude those conditions requiring urgent, and possibly life-saving, management.
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Evaluating patient outcomes is essential in a healthcare environment focused on quality. Mortality after surgery has been considered a useful quality metric. More important than mortality rate, failure to rescue (FTR) has emerged as a metric that is important and may be improveable. The purpose of this review is to define FTR, describe patient and hospital level factors that lead to FTR, and highlight possible solutions to this problem. ⋯ FTR is a major clinical concern and efforts aimed at optimizing patient and hospital factors, culture and communication, as well as early identification of the deteriorating patient may improve FTR rate.
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Curr Opin Crit Care · Dec 2019
ReviewEmergency bedside ultrasound: benefits as well as caution - part 1. General.
The use of bedside or point-of-care ultrasound (POCUS) in medical emergencies is rapidly becoming more established as an effective acute diagnostic tool. The purpose of this review is to provide an overview of the various techniques currently used that are readily available, as well as several in development. Possible caveats are also addressed. ⋯ We believe that a core level of POCUS should be achievable by practicing clinicians. Ultimately, the integration of POCUS findings into a patient management strategy must be holistic, and hence requires prudent consideration of the clinical scenario.