Current opinion in critical care
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This review explores the contemporary definition of the term 'balanced crystalloid' and outlines optimal design features and their underlying rationale. ⋯ The case for balanced crystalloids is growing but unproven. A large randomized controlled trial of balanced crystalloids versus 0.9% sodium chloride is the next step.
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This review summarizes the current evidence base for commonly transfused blood components with a particular focus on the nonacutely bleeding patient. ⋯ As all blood components have some level of risk, the general approach to transfusion should be one of minimization. For the nonacutely bleeding critically ill patient, a RBC transfusion trigger of 70 g/l is clinically acceptable. For patients at potentially higher risk of adverse effects related to anemia such as those with septic shock, severe and/or acute ischemic heart disease, or brain injury, a higher threshold (80-90 g/l) may be considered. There is insufficient evidence to recommend specific thresholds for transfusion of frozen plasma or platelets in the critically ill.
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Curr Opin Crit Care · Aug 2013
ReviewReappraising Starling: the physiology of the microcirculation.
Vascular permeability is traditionally explained by Starling's principle, describing two opposing forces across the endothelial cell line to maintain compartments in balance. Several contradictions to this principle have recently questioned its validity. ⋯ Starling's principle requires an adaptation to recognize that there is no inward-directed oncotic pressure gradient across the whole anatomical vessel wall. The carrier of vascular barrier competence is the intact endothelial surface layer which might be protected by avoiding intravascular hypervolaemia and limiting inflammation.
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To review recent studies and information on the relationship between fluid administration and kidney function in critically ill patients. ⋯ Clinicians need to weigh the balance between adequate resuscitation of cardiac output and avoidance of fluid overload. Protocolized resuscitation to hemodynamic goals may help achieve these conflicting goals at least in the early phases of critical illness. In critically ill patients with, or at risk of, AKI, clinicians should avoid starch and, possibly, saline solutions.
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This review examines the long-term influence of postoperative complications on survival. Although it is intuitive that complications after surgery worsen short-term outcomes, it is not clear to what extent and why a longer-term relationship may exist. ⋯ Patients that develop postoperative complications and survive the immediate risk period, demonstrate worsened long-term mortality. The field of perioperative medicine is increasingly mandated to identify vulnerable individuals, develop and implement strategies to prevent and treat complications, and provide better care pathways after hospital discharge.