Current opinion in critical care
-
Curr Opin Crit Care · Dec 2018
ReviewAn update on membranes and cartridges for extracorporeal blood purification in sepsis and septic shock.
This review aims to summarize the most recent advances on different membranes and cartridges used for extracorporeal blood purification in critically ill patients with sepsis or septic shock. ⋯ None of the discussed specific membranes or cartridges can currently be recommended as sole adjunctive treatment in sepsis and septic shock. Any available technique should be timely initiated and adapted to the patient's status. Sickest patients seem to benefit more from blood purification. Patient selection is thus of crucial importance and may be optimized by focusing on disease severity and degree of organ failure. Measurement of endotoxin activity and plasma procalcitonin levels can support the selection process but ideal cutoff values need to be defined. Well-designed prospective randomized clinical trials assessing or comparing the various available membranes and cartridges are eagerly awaited.
-
Curr Opin Crit Care · Dec 2018
ReviewContinuous renal replacement therapy: understanding circuit hemodynamics to improve therapy adequacy.
The utilization of continuous renal replacement therapy (CRRT) increases throughout the world. Technological improvements have made its administration easier and safer. However, CRRT remains associated with numerous pitfalls and issues. ⋯ CRRT circuits' maximum recommended lifespan (72 h) can often not be achieved. Such early artificial kidney failures are typically related to two processes: circuit clotting and membrane clogging. Although these processes are to some degree inevitable, they are facilitated by poor therapy management. Indeed, the majority of device-triggered alarms are associated with blood pump interruption, which through blood stasis, enhance clotting and clogging. If the underlying issue is not adequately managed, further alarms will rapidly lead to prolonged stasis and complete circuit clotting or clogging making its replacement mandatory. Hence, rapid recognition of issues triggering alarms is of paramount importance. Because most alarms are related to circuit's hemodynamics, a thorough understanding of these concepts is mandatory for the staff in charge of delivering the therapy.This review describes CRRT circuits, measured and calculated pressures and the way their knowledge might improve therapy adequacy.
-
The volume of bariatric and nonbariatric surgical procedures on obese patients is dramatically increasing worldwide over the past years. In this review, we discuss the physiopathlogy of respiratory function during anesthesia in obese patients, the stratification of perioperative risk to develop intraoperative and postoperative pulmonary complications, the optimization of airway management, and perioperative ventilation, including postoperative respiratory assistance. ⋯ Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.
-
Curr Opin Crit Care · Dec 2018
ReviewPersonalization of arterial pressure in the perioperative period.
This review aims to discuss recent findings on the relationship between intraoperative arterial hypotension and organ dysfunction in surgical patients and examines the available evidence for personalizing blood pressure (BP) management as a strategy to improve patient outcome. ⋯ Hypotension is a common complication in surgical patients and is an important trigger of organ injury in surgical patients. Personalized BP management may contribute at reducing postoperative organ dysfunction in surgical patients.
-
Avoidance and treatment of hypoxaemia is a cornerstone of acute resuscitation and yet the optimal approach to oxygen therapy in the acute care setting is uncertain. The aim of this review is to appraise recent evidence relating to the provision of supplemental oxygen to adult patients with acute illnesses with a focus on the resuscitation phase. ⋯ At present, evidence is lacking to support routine liberal oxygen administration in acutely ill patients and, in most circumstances, a reasonable approach is to titrate supplemental oxygen to achieve an arterial oxygen saturation measured by pulse oximetry (SpO2) of 92-96% with the aim of avoiding both hypoxaemia and hyperoxaemia.