Current opinion in critical care
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Surgical incision invariably causes some measure of nerve damage and inflammatory response that, in most cases, heals quickly without long-term negative consequence. However, a subset of these patients go on to develop lasting neuropathic pain that is difficult to treat and, in many cases, prevents the return to normal activities of life. It remains unknown why two patients with identical surgical interventions may go on to develop completely divergent pain phenotypes or no pain at all. Aggressive, early analgesic therapy has been shown to reduce the incidence of chronic postsurgical pain (CPSP), but no specific regional anesthetic technique or systemic pharmacologic therapy has been shown to prevent CPSP. ⋯ Here, we discuss the causes of CPSP and current useful preventive strategies in the perioperative period. We also discuss future potential disease-modifying treatments of CPSP.
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Curr Opin Crit Care · Aug 2012
ReviewThe use of simulation in healthcare: from systems issues, to team building, to task training, to education and high stakes examinations.
Simulation in healthcare is becoming increasingly used. This review will spotlight some of the uses of simulation in healthcare training. ⋯ This article will review some recent studies showing how simulation can have a positive effect on patient outcomes and skill retention, uncover systems issues related to patient safety, and how simulation can be used in credentialing, and other high stakes examinations.
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Curr Opin Crit Care · Aug 2012
ReviewLess-invasive approaches to perioperative haemodynamic optimization.
A number of less-invasive haemodynamic monitoring devices have been introduced in recent years, largely replacing the pulmonary artery catheter (PAC) as a standard monitoring tool. Apart from tracking cardiac output (CO), these monitors provide additional haemodynamic parameters. The aim of this article is to review the most widely used less-invasive monitoring modalities, their technical characteristics and limitations regarding their clinical performance. ⋯ An array of monitoring modalities have been introduced that can reliably track CO in the perioperative setting and make the PAC dispensable in most clinical situations. In order to be used safely and efficiently, knowledge regarding the inherent monitoring techniques and their limitations, their clinical validity and the utility of the parameters provided is crucial.
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Curr Opin Crit Care · Aug 2012
ReviewEarly emergency management of acute decompensated heart failure.
Acute decompensated heart failure (ADHF) is characterized by a complex spectrum of pathophysiology that emerges as a common clinical disease state, which manifests as a failure of the circulation to provide for the needs of the body systems. Whereas ADHF is often characterized by the findings of pulmonary congestion and dyspnea, a variety of clinical presentations are possible, with each requiring differing management strategies. This review examines the approach of the four-quadrant clinical profile for differentiation of the ADHF patient during the emergent resuscitative phase of the decompensation. ⋯ ADHF can present in a variety of clinical forms in the emergent setting. Categorization of the ADHF patient according to their individual hemodynamic profile can assist in management decisions during the emergent resuscitative phase of the decompensation based upon an approach that targets causative pathophysiologic mechanisms.
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Curr Opin Crit Care · Aug 2012
ReviewDo sepsis biomarkers in the emergency room allow transition from bundled sepsis care to personalized patient care?
There is convincing evidence linking early start of fluid resuscitation and initiation of appropriate antimicrobial therapy to improved outcomes in patients with sepsis in the emergency department. Blood biomarkers measured on admission and during follow-up have the ability to guide early sepsis recognition, severity assessment and therapeutic decisions in individual patients and may allow transition from bundled sepsis care to more individualized management in single patients. ⋯ For few biomarkers, recent study results demonstrate that well defined clinical protocols have the potential to guide decisions about the individual risk stratification and treatment of patients with suspicion of sepsis ultimately leading to improved patient care and outcomes. For other biomarkers, promising observation data have been put forward, but their potential needs to be evaluated in large-scale, well designed prospective intervention studies before clinical use can be recommended.