Current opinion in critical care
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Curr Opin Crit Care · Aug 2019
ReviewLactate and other biomarkers as treatment target in cardiogenic shock.
Cardiogenic shock remains beside sudden cardiac death the most outcome relevant complication of acute myocardial infarction. Over the last two decades as confirmation of the benefit of early revascularization no further relevant improvement in outcome could be achieved. Biomarkers are important for diagnosis, monitoring, and management in cardiogenic shock patients. ⋯ Biomarkers serve as important treatment targets and may help physicians in therapeutic decision-making. Furthermore, the complex pathophysiology of cardiogenic shock may be better understood by investigation of different biomarkers.
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Glutamine (GLN) is a versatile amino acid, long believed to have important implications in ICU and surgical patients. An extensive body of data examining GLN supplementation of TPN demonstrated a consistent signal of improved outcomes. However, recently signals of risk have come from two large-scale multicenter trials evaluating GLN (and other nutrients) at high dose and as primary pharmaconutrients, not as supplementation to complete nutrition. These trials indicate a risk of increased mortality when GLN is given to patients in shock, renal failure, and early in acute phase of critical care. ⋯ Three recent meta-analyses have confirmed traditional GLN-supplemented (or 'GLN-Complemented' - providing GLN for completeness of amino acid content) TPN is safe, reduces mortality and improves outcome in surgical and ICU patients. Patients in need of TPN, burns, trauma or malignancies should continue to benefit from supplemental GLN, administered either intravenously at less than 0.35 g/kg/day or enterally at less than 0.5 g/kg/day. Further, a large trial of EN GLN supplementation in burns is ongoing. Thus, when used per guideline recommendations, the GLN story is likely still relevant to ICU outcomes and research.
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Curr Opin Crit Care · Aug 2019
ReviewCardiogenic pulmonary edema: mechanisms and treatment: an intensivist's view.
This review summarizes current understanding of the pathophysiology of cardiogenic pulmonary edema, its causes and treatment. ⋯ Treatments must be initiated early, whereas evaluation still is occurring and requires multimodality intervention. The general treatment of cardiogenic pulmonary edema includes diuretics, possibly morphine and often nitrates. The appropriate use of newer approaches - such as, nesiritide, high-dose vasodilators, milrinone, and vasopressin receptor antagonists - needs larger clinical trials.
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Curr Opin Crit Care · Jun 2019
ReviewAn international, consensus-derived Core Outcome Set for Cardiac Arrest effectiveness trials: the COSCA initiative.
Accurate and relevant assessment is essential to determining the impact of ill-health and the relative benefit of healthcare. This review details the recent development of a core outcome set for cardiac arrest effectiveness trials - the COSCA initiative. ⋯ The COSCA recommendation describes a small group of outcomes that should be reported as a minimum across large, randomized clinical effectiveness trials for cardiac arrest.