Current opinion in critical care
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To discuss trends in the use of osmotic therapy. ⋯ The existing data do not support favoring boluses of hypertonic saline over mannitol in terms of ICP control, let alone outcome. The rationale for continuous infusions to create a sustained hyperosmolar state is open to discussion and use of this approach should be curtailed pending further research.
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Curr Opin Crit Care · Apr 2013
ReviewCirrhotic patients in the ICU: prognostic markers and outcome.
Give an update on the importance of prognostic scores at admission to the ICU for defining short-term outcome in critically ill cirrhotic patients. Highlight the correlation between the development of sepsis and/or organ failure and outcome. ⋯ Early referral of cirrhotic patients to ICU before the development of multiple extrahepatic organ failure is essential to improve outcome. Current scores should be used only for clinical trials and not to determine the potential futility or costs of an ICU admission.
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Curr Opin Crit Care · Apr 2013
ReviewClearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage.
Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments. ⋯ IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.
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The mortality in patients suffering from liver failure decreased in line with medical progress over the past decades. However, it still remains unacceptably high and liver transplantation still provides the only definite treatment for many patients. The goal of extracorporeal liver support systems is to improve the clinical condition of patients waiting for liver transplantation and/or enhance the regeneration of native injured liver. Nonbiological liver support systems with pure detoxification and biological liver support systems with assumed synthesis and metabolism in addition to detoxification are currently under clinical investigation. Since patient survival is the most significant outcome parameter, we focus in this review on prospective randomized trials with survival rate as primary outcome parameter. ⋯ The future development of liver support systems may provide different combinations of new adsorbents, integrated regional citrate anticoagulation and eventual substitution of irreversibly damaged albumin.
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Curr Opin Crit Care · Apr 2013
ReviewDecompressive craniectomy in traumatic brain injury after the DECRA trial. Where do we stand?
The results of the multicentre, randomized, controlled trial to test the effectiveness of decompressive craniectomy in adults with traumatic brain injury and high intracranial pressure (Decompressive Craniectomy, DECRA) were published in 2011. DECRA concluded that decompressive craniectomy decreased intracranial pressure (ICP) but was associated with more unfavourable outcomes. Our review aims to put the DECRA trial into context, comment on its findings and discuss whether we should include decompressive craniectomy in our clinical armamentarium. ⋯ The claim that decompressive craniectomy increases unfavourable outcome is overstated and not supported by the data presented in DECRA. We believe it premature to change clinical practice. Given the dismal outcome in these patients, it is reasonable to include this technique as a last resort in any type of protocol-driven management when conventional therapeutic measures have failed to control ICP, the presence of operable masses has been ruled out and the patient may still have a chance of a functional outcome. The main lesson to be learned from this study is that an upper threshold for ICP must be used as a cut-off for selecting decompressive craniectomy candidates.