Current opinion in critical care
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Curr Opin Crit Care · Jun 2019
ReviewHemodynamic monitoring in the extracorporeal membrane oxygenation patient.
Hemodynamic monitoring in ECMO patients requires familiarity with the underlying pathophysiology and circulatory mechanics of extracorporeal flow. This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarterial (VA ECMO). We emphasize tools to judge the adequacy of perfusion, predict the response to fluid boluses, measure right ventricular function, assess left ventricular distention (for VA ECMO), and monitor the process of weaning from ECMO. We emphasize how differences between VV ECMO and VA ECMO are reflected in distinct approaches to monitoring. ⋯ Recent literature in hemodynamic monitoring of ECMO patients is discussed, with comparison of VV ECMO and VA ECMO. Many common monitoring tools lack validity during ECMO: by taking into account the unique physiology of the ECMO circulation, selected methods can aid in the care of these complex patients.
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Curr Opin Crit Care · Jun 2019
ReviewOut-of-hospital cardiac arrest survivors need both cardiological and neurological rehabilitation!
Most survivors of out-of-hospital cardiac arrest (OHCA) suffer from cardiologic symptoms and approximately half of them experience cognitive problems because of hypoxic brain damage. Symptoms of anxiety and depression are also common. This review aims to give an overview of recent literature on rehabilitation treatment aiming at improvement of quality of life after OHCA. ⋯ OHCA survivors should be routinely screened for cognitive and emotional problems. When patients with mild cognitive deficits participate in cardiac rehabilitation, their program should be adjusted to their cognitive abilities. For patients with severe cognitive or emotional problems, individualized rehabilitation seems favorable. Integrated rehabilitation treatment between cardiac and cognitive rehabilitation departments is recommended. Attention should be paid to the burden of caregivers.
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Shock, best defined as acute circulatory failure is classified into four major groups, namely hypovolemic, cardiogenic, obstructive, and distributive (vasodilatory). The purpose of this review is to provide a practical approach to fluid optimization in patients with the four types of shock. ⋯ We believe that the approach to fluid therapy must be individualized based on the cause of shock as well as the patient's major diagnosis, comorbidities and hemodynamic and respiratory status. A conservative, physiologically guided approach to fluid resuscitation likely improves patient outcomes.
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The purpose of the review is to briefly describe the derivation, validation and implementation of the Termination of Resuscitation Rules for out-of-hospital adult cardiac arrest and to describe the controversies surrounding implementation that have been recently published. ⋯ The Universal Termination of Resuscitation Rule has a built-in sensibility to the introduction of new treatment guidelines, including emphasis on CPR metrics, changes in baseline survival rates, duration of resuscitation and new treatment options including eCPR and postarrest care. As well, the TOR rule continues to address inconsistencies in practice and improve provider comfort.
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Curr Opin Crit Care · Jun 2019
ReviewEchocardiographic assessment of left ventricular diastolic pressure.
Knowledge of the left ventricular pressures throughout the cardiac cycle is of considerable assistance in managing a haemodynamically unstable patient. Invasive pressure measurement is the only accurate way to analyze ventricular diastolic pressures but this is not feasible outside the catheterization laboratory, whereas the use of a pulmonary artery catheter or Doppler echocardiography, using surrogate measurements, is available at the bedside. The ever-increasing trend toward noninvasive monitoring puts echocardiography at the forefront and considerable effort has been made to define its role in this setting. ⋯ The recent literature on the clinical application of echocardiography on the accuracy in determining left ventricular noninvasively demonstrates that although far from perfect, it can be a very useful tool.