Current opinion in critical care
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Curr Opin Crit Care · Aug 2017
ReviewLactate and microcirculation as suitable targets for hemodynamic optimization in resuscitation of circulatory shock.
A discussion of recent research exploring the feasibility of perfusion-guided resuscitation of acute circulatory failure with a focus on lactate and microcirculation. ⋯ Although questions remain, a multimodal perfusion-based approach to resuscitation is emerging with lactate and microcirculation as core measures. In this model, hyperlactemia and microcirculatory derangement support the diagnosis of shock, may help guide resuscitation during the initial period, and may reflect resuscitation efficacy and iatrogenic harm (e.g., fluid overload).
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Curr Opin Crit Care · Aug 2017
Muscle mass and physical recovery in ICU: innovations for targeting of nutrition and exercise.
We have significantly improved hospital mortality from sepsis and critical illness in last 10 years; however, over this same period we have tripled the number of 'ICU survivors' going to rehabilitation. Furthermore, as up to half the deaths in the first year following ICU admission occur post-ICU discharge, it is unclear how many of these patients ever returned home or a meaningful quality of life. For those who do survive, recent data reveals many 'ICU survivors' will suffer significant functional impairment or post-ICU syndrome (PICS). Thus, new innovative metabolic and exercise interventions to address PICS are urgently needed. These should focus on optimal nutrition and lean body mass (LBM) assessment, targeted nutrition delivery, anabolic/anticatabolic strategies, and utilization of personalized exercise intervention techniques, such as utilized by elite athletes to optimize preparation and recovery from critical care. ⋯ New innovative techniques are demonstrating promise to target recovery from PICS utilizing a combination of objective LBM and metabolic assessment, targeted nutrition interventions, personalized exercise interventions for prehabilitation and post-ICU recovery. These interventions should provide hope that we will soon begin to create more 'survivors' and fewer victim's post-ICU care.
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To review the recent findings on metabolic derangements leading to loss of muscle mass and function. ⋯ Muscle mass and function are related to outcome. New finding show that not only muscle mass but also muscle quality is important, that a compromised handling of calcium might be involved in muscle weakness and that regaining muscle could be compromised due to a defective regenerative capacity of satellite cells.
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Protein delivery as well as exercise of critically ill in clinical practice is still a highly debated issue. Here we discuss only the most recent updates in the literature concerning protein nutrition and exercise of the critically ill. ⋯ Optimal protein nutrition, optimal exercise intervention as well as the optimal combination of nutrition, and exercise may help to improve long-term physical performance outcome in the critically ill patients.
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Norepinephrine is the first-line agent recommended during resuscitation of septic shock to correct hypotension due to depressed vascular tone. Important clinical issues are the best timing to start norepinephrine, the optimal blood pressure target, and the best therapeutic options to face refractory hypotension when high doses of norepinephrine are required to reach the target. ⋯ Early administration of norepinephrine is beneficial for septic shock patients to restore organ perfusion. The mean arterial pressure target should be individualized. Adding vasopressin is recommended in case of shock refractory to norepinephrine.