Current opinion in critical care
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To summarize is to review recent progress in 'genomic' science and how this may be applied to the perioperative environment. Although investigations that relate genetic variation to perioperative outcomes continue, it is increasingly apparent that epigenetic mechanisms may contribute to much of the observed variation in complex outcomes not otherwise explained by differences in genetic sequence. ⋯ Enhancing our understanding of the way in which patients as genomic organisms interact with the perioperative environment requires a more sophisticated appreciation of the factors governing gene expression than has been the case to date. Epigenetic mechanisms are sure to play a pivotal role in what is essentially an acquired phenotype.
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Curr Opin Crit Care · Oct 2012
ReviewHeart rescue: the role of mechanical circulatory support in the management of severe refractory cardiogenic shock.
Cardiogenic shock is present in 3.5% of patients presenting with acute decompensated heart failure. Despite advances in therapy, mortality remains high, approaching 70% in some settings. Recent management strategies have incorporated the use of mechanical circulatory support (MCS), which has been associated with better survival in nonrandomized trials. MCS is increasingly used in the acute setting and has become an important treatment modality for cardiogenic shock. ⋯ This article will review novel strategies in the management of cardiogenic shock including percutaneous MCS (intra-aortic balloon pump, Impella, TandemHeart, venoarterial extracorporeal membrane oxygenation) and surgically implanted devices (CentriMag) that are used for short-term management. We will review the mechanisms involved in cardiogenic shock and discuss management and device selection strategies.
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Curr Opin Crit Care · Oct 2012
ReviewWhat is the niche for extracorporeal membrane oxygenation in severe acute respiratory distress syndrome?
This article reviews the results of case series and trials which evaluated venovenous extracorporeal membrane oxygenation (VV-ECMO) for severe respiratory failure. Potential indications of the technique in this setting are discussed. ⋯ Before widespread diffusion of VV-ECMO for severe ARDS, new trials should test the efficacy of early initiation of the technique with tight control of mechanical ventilation in the control group, initiation of ECMO prior to transportation to ECMO centers, and the use of ECMO in every patient randomly assigned to receive it.
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As numbers of patients who survive a critical illness increase, often within a context of comorbidities and acquired physical, mental or cognitive sequelae [postintensive care syndrome (PICS)], identifying effective recovery and rehabilitation strategies is paramount. In this review, we discuss recent studies that inform our developing understanding for improving the recovery trajectory for survivors of a critical illness during the postintensive care and posthospital periods. ⋯ Innovative rehabilitation and recovery strategies during the postintensive care and posthospital periods are now being published. Further research with larger sample sizes, well-documented usual care and intervention arms and in different critical illness cohorts is required to demonstrate the optimal approaches for screening, implementation, outcome assessment and follow-up periods for rehabilitation interventions in the postintensive care phase of a patient's recovery.
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Lung transplantation (LTx) has become established as a standard intervention for patients suffering from end-stage lung disease. Transplant recipients are, however, predisposed to numerous unique complications arising from the surgery, transplant immunology and the lifelong medication. Clinicians working in intensive care are increasingly likely to be exposed to these patients and it is therefore important to have a working knowledge of the common complications. ⋯ This review highlights the most important complications after LTx and gives an update on diagnostic algorithms and treatment challenges for patients following LTx.